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PLATE I. 




Photographic view of the Chest, showing the outline of the Heart, Liver and Stomach on the living 

snhiprt 



subject. 



PLATE II. 




Photographic view of the Back, showing the outline of the Lungs, Kidneys, and lower margin of the 

Liver on the living subject. 



HOW TO EXAMINE 



FOR 



LIFE" INSURANCE. 



JOHN M. KEATING, M. D., 

PRESIDENT OF THE ASSOCIATION OF LIFE INSURANCE MEDICAL 
DIRECTORS, ETC. 







PHILADELPHIA: 

1890. 






Copyrighted, 1890, by J. M. Keating, m.d. 



PRESS OF WM F. FELL 4 CO. 

1220-24 SANSOM STREET, 

PHILADELPHIA. 



PREFACE 



The aim in writing this book has been to give to the Medical Examiner 
for Life Insurance a manual which is plain and practical, free from 
matters that are not of direct interest to him in the examination of an 
applicant for insurance, but at the same time sufficiently instructive to 
recall to his mind all the important points in relation to physical diag- 
nosis that are likely to be of value to him. A physician who intends to 
examine for Life Insurance should especially prepare himself by a close 
study of such excellent works as Da Costa's " Medical Diagnosis," Fin- 
layson's "'Clinical Diagnosis " and Tyson's " Practical Examination of 
Urine." An Examiner's duties are simply to portray to the Home 
Office, in as clear and concise a manner as possible, the medical history, 
the actual condition of the applicant, and all that pertains to his health 
and its probable maintenance. The laws of average and the selection of 
lives are of little interest to him in the field ; he needs to be reminded 
of the instructions from his Company, and how to accomplish his work 
in as thorough and expeditious a manner as possible. 

There is nothing absolutely original in this work, as there is very little 
new to be said on the subject of physical diagnosis, but I have endeavored 
as far as possible to collect what is of value from the text-books, and also 
from the Life Insurance works that have recently appeared. I have had 
occasion to quote freely from the excellent little manual of "Essentials of 
Physical Diagnosis," by J. Wallace Anderson, and have found it advisable, 
owing to the concise manner in which matters are therein treated, to make 
little alteration in the language of the parts quoted. I am also indebted 
to Dr. Geo. McClellan for the diagram (Plate 3) which he drew from 
a special dissection made for this purpose, and also for his assistance in 
the preparation of the two photographic illustrations. I also desire to 
express my thanks to the Medical Directors of the Companies whose 
instructions appear in Part II. Not only were these gentlemen kind 



IV PREFACE. 

enough to send them to me, but they also revised the proofs, so that 
these form the latest instructions that are issued by the Medical Depart- 
ments of the Companies, and greatly enhance the value of the work. 

Jesse J. Barker, Esq., Actuary, aided me in the preparation of the 
matter for Chapters I and II. 

Dr. O. P. Rex read the proof of the section on Physical Diagnosis, 
and Prof. James Tyson kindly revised the chapter on the Examination 
of the Kidneys. J. M. K. 

128 So. 18th St., Philadelphia. 



CONTENTS. 



PART I. 

CHAPTER I. p AGE 

Life Insurance, , 9 

CHAPTER II. 

Medical' Examiner, 10 

Special Duties of an Examiner, 1 1 

CHAPTER III. 
The Examination of an Applicant, 13 

CHAPTER IV. 
Habits, 17 

CHAPTER V. 

The Pulse, . 20 

The Sphygmograph, 21 

CHAPTER VI. 
Height and Weight, 23 

CHAPTER VII. 
Examination of the Heart, 25 

CHAPTER VIII. 
Examination of the Chest, 33 

CHAPTER IX. 
Examination of the Lungs, 36 

CHAPTER X. 
Incipient Phthisis, 43 

CHAPTER XL 
Examination of the Abdomen, Liver and Bowels, 47 

CHAPTER XII. 

Examination of the Kidneys, 49 

Specific Gravity, 50 

Albumin, 51 

V 



VI CONTENTS. 

PAGE 

Sugar, 52 

Directions for the Use of the Saccharometer, 54 

Urea, 55 

Directions for the Use of the Ureometer, 56 

Microscope, 58 

Diseases of the Genito- Urinary Organs, 62 

CHAPTER XIII. 

Nervous System, 63 

CHAPTER XIV. 

Examination of Women, 64 

CHAPTER XV. 

Summary, 65 



PART II. 



INSTRUCTIONS TO MEDICAL EXAMINERS AS ISSUED BY THE 
VARIOUS LIFE INSURANCE COMPANIES. 

^Etna Life Insurance Company, 69 

Brooklyn Life Insurance Company, 73 

Connecticut General Life Insurance Company, 81 

Connecticut Mutual Life Insurance Company, 85 

Equitable Life Assurance Society of the United States, ...... 87 

Home Life Insurance Company, 97 

John Hancock Mutual Life Insurance Company, 113 

Life Insurance Company of Virginia, 119 

Maryland Life Insurance Company, 123 

Massachusetts Mutual Life Insurance Company, 125 

Michigan Mutual Life Insurance Company, 131 

Mutual Benefit Life Insurance Company, 135 

Mutual Life Insurance Company of New York, 139 

National Life Insurance Company, 145 

New England Mutual Life Insurance Company, 147 

New York Life Insurance Company, 151 

Northwestern Masonic Aid Association, 165 

Northwestern Mutual Life Insurance Company, 171 

Penn Mutual Life Insurance Company, 177 

Phcenix Mutual Life Insurance Company, 181 

Provident Savings Life Assurance Company, 185 

Union Central Life Insurance Company, 189 

Union Mutual Life Insurance Company of Maine, 193 

Washington Life Insurance Company, 205 

Specimen Form of an Application and a Medical Examination Blank, 209 



PART I. 



DETAILS OF THE EXAMINATION 



HOW TO EXAMINE FOR LIFE INSURANCE. 



CHAPTER I. 

LIFE INSURANCE. 



Life Insurance is a contract of indemnity, a contract between a 
Life Insurance Company and the applicant for insurance, by which 
in consideration of the truth of the statements made in the applica- 
tion and those made to the Examiner, as to the present and pre- 
vious health and habits of the party to be insured, and of the pay- 
ment to the Company of the premiums required by the kind of 
policy desired, the Company agrees to pay at the death of the party 
insured, or at some other period, as in the case of an endowment 
policy, a certain amount of insurance. 

The contract therefore is not valid and in fact never existed in 
case of fraud or concealment on the part of the applicant or per- 
son whose life is to be insured : and as this is so, and to avoid 
disputes, and misunderstandings, it is necessary that the Medical 
Examiner be careful to have not only all questions fully answered 
by the applicant, but all doubtful medical points cleared up, before 
the risk is accepted or the policy issued. Hence much depends 
upon the care and skill of the Medical Examiner and upon the 
thoroughness of his work. 

" The general object or purpose of an Insurance Company is to 
afford indemnity or security against loss ; its engagement is not 
founded on any philanthropic, benevolent or charitable principle ; 
it is a purely business adventure in which one, for a stipulated con- 
sideration or premium per cent., engages to make up wholly or in 
part, or in a certain agreed amount, any specified loss which another 
may sustain. To grant indemnity or security against loss for a 
consideration is not only the design and purpose of an Insurance 
Company, but it is also the dominant and characteristic feature of 
the contract of insurance." — Decision of the Supreme Court of Penn- 
sylvania. 

Therefore speculative insurance is contrary to law. 

9 



10 HOW TO EXAMINE FOR LIFE INSURANCE. 

KINDS OF INSURANCE. 

All the different kinds of insurance may be resolved into two 
main classes. Life and Endowment policies. Life policies are 
payable only at the death of the insured, and Endowment policies 
are payable at a fixed time, or at the prior death of the insured. 

The premiums on these policies are payable by the insured, either 
continuously during the continuance of the insurance, called " Regu- 
lar Payments," or may be payable for ten, fifteen or twenty years 
only, called " Limited Payments," and at the end of this time the 
policy becomes full paid. In the case of the limited payments the 
premiums to be paid yearly are necessarily the greater the shorter 
the period they are to continue. 

What are called " Semi-Tontine," " Five Year Distribution," 
" Reversionary Additions," " Accumulated Surplus " policies, etc., 
are simply modifications of the two great plans, affecting merely 
the method of applying the dividends of surplus, allowed by the 
Company, and have no bearing, medically or otherwise, on the 
grand divisions of insurance above referred to. 



CHAPTER II. 

MEDICAL EXAMINER. 



The Medical Examiner sustains a peculiar relation while making 
the examination. He is the Agent of the applicant while recording 
the answers of the latter to the questions concerning his family and 
personal medical history ; he should be extremely careful in writing 
his answers to avoid inaccuracy in his statement or uncertain 
expressions. He is also the confidential Medical Representative 
of the Company and is required to guard the interests of both : 
of the applicant in so far that trivial matters may not be exaggerated 
into unnecessary importance, and of the Company, that nothing 
needing investigation or consideration at the Home Office, may be 
overlooked. His judgment therefore must be nicely balanced and 
closely discriminating. 

Unless the family history is very bad, the judgment of the Ex- 



SPECIAL DUTIES OF AN EXAMINER. I I 

aminer should be made up mainly upon the personal condition of 
the applicant, as to whether or not he should be recommended for 
a policy. Then too there are cases where through some hereditary 
tendency the applicant may reasonably be considered to be a safe 
risk for 10, or 15, or perhaps 20 years, after which some hereditary 
taint in the family appears to develop, and terminate life. In these 
cases the risk might be accepted for an endowment policy running 
until the doubtful period is reached. 

In other cases occupations seem to shorten life, as with glass 
blowers, stone cutters, axe grinders, polishers, etc. Here ten 
or fifteen years of such work usually develops consumption or 
some lung disease, and if these cases are accepted at all the insur- 
ance should terminate in ten or at the most fifteen years. 

When an insured member dies, a Medical Examiner is frequently 
called on, as the attending physician, to fill out the physician's 
certificate on the Proofs of Loss. In such a case he should give 
all the information he can relating to the health of the applicant, 
both before and after the taking of the insurance, and especially 
all the particulars necessary to' obtain a clear idea of the predis- 
posing causes of the last illness, of its first appearance, and a concise 
history of its progress and end. 

SPECIAL DUTIES OF AN EXAMINER. 

The position of a Medical Examiner for a Life Insurance Com- 
pany is one that carries with it a degree of responsibility and an 
amount of work which at times does not receive its equivalent, 
pecuniarily. 

In some Agencies, owing, possibly, to the natural business tact of 
the Agent, or to the peculiar class of individuals that he insures — 
men doing a large business, and who are accustomed to appreciate 
the value of appointments and the economization of time — the Med- 
ical Examiner will find that his work does pay, and that, on the 
whole, it is an extremely agreeable position to hold; one in every way 
satisfactory, and of the greatest advantage to him ; by bringing him 
in contact with business men, he is enabled to make their acquain- 
tance 'under auspices which naturally make an impression upon 
them — a medical representative of an institution in which they 
have confidence to insure their lives. 

The annoyances in an Examiner's life are at times extreme. He 
has been selected by the Company owing to his especial fitness ; 



12 HOW TO EXAMINE FOR LIFE INSURANCE. 

he has the burden of their interests upon him, and they depend 
upon him for information of the most confidential character, which 
will enable them to make a proper decision in the case, and to issue 
a policy or not. Matters may have come before him which neces- 
sarily have unfavorably impressed him in regard to the insurability 
of the applicant. These may be simply matters of hearsay or 
general repute, but nevertheless they should form part of his report 
to the Company, if he is a conscientious man, and it is the duty of 
the Company to investigate such reports. 

It does not take a very good guesser — and Life Insurance Agents 
are usually adepts in this line — to recognize at once that these state- 
ments have come through the Company's Examiner, and frequently 
an antagonistic feeling is established between the Agent and Ex- 
aminer which the business relations of both to the Home Office 
naturally make stronger as time goes on. The Agent, however 
conscientious he may be, if he is working on commission, naturally 
feels that it is through the Examiner's report that his applicant has 
been refused insurance, and he feels that more careful consideration 
of the case, less conscientiousness on the part of the Examiner, 
and a more liberal spirit exhibited by the Medical Department at 
the Home Office, would have saved this risk for him. 

There are undoubtedly questions that frequently arise in which 
the Company is given the benefit of the doubt, and rightly so, and 
these cases form the basis upon which differences of opinion between 
the Medical Examiner and the Agent exists. 

Then, again, an Examiner for Life Insurance often feels that he 
has more than earned his compensation by the numberless unsatis- 
factory trips that he has taken to meet unkept appointments, the 
difficulty of securing a thorough and careful examination, such as he 
would like to report to his Company, the investigations which he 
has been obliged to make owing to false statements made by the 
applicant, or the omission of matters that are of vital importance in 
the decision at the Home Office, questions of personal history, of 
heredity, of occupation or habits, involving two or more visits, and 
probably taking up hours of valuable time. 

The Medical Department of a Home Office recognizes all these 
facts, and studies both sides of the question, and from my personal 
knowledge of the action of all the largest Companies, through the 
personal acquaintance of the Medical Directors and their associates, 
I feel convinced that they endeavor, as far as they are able, to sup- 



THE EXAMINATION OF AN APPLICANT. 1 3 

port their Medical Examiners, and give them credit for all the 
conscientious work that they do. 

The Examiner in all cases should thoroughly acquaint himself 
with the particular rulings of the Company for which the examina- 
tion is to be made. These instructions are at times difficult to 
remember, unless they have been carefully read and studied, and 
the differences peculiar to the various Companies have been noted. 

One object of this manual is to have in a compact form the 
instructions that have been issued by the various Companies doing 
business in these United States, so that the Examiner can turn 
at once to the section which contains all the instructions issued 
by the Medical Department of each Company, and in this way 
fulfill these requirements. 



CHAPTER III. . 

THE EXAMINATION OF AN APPLICANT. 

When an applicant is presented to an Examiner, or an Examiner 
has been asked to visit one, to make an examination, it must be 
always borne in mind that, in a large majority of cases, the individual 
has not sought the insurance of his own free will, but has been 
convinced of the necessity of insuring his life, and the character of 
the policy which the Agent has shown him has struck his fancy, 
and he has decided to submit himself for examination. Naturally, 
if much time is lost before he is examined, he will cool off, or some 
other Agent, with more persuasive powers than the first, will con- 
vince him that his Company offers a contract which, in many 
respects, is more suited to him. It becomes, therefore, the duty of 
the Examiner, who has accepted the position from the Company, to 
at once attend to this matter of examination, to let no time elapse, 
but endeavor, as far as possible, to postpone for a short time other 
outstanding engagements that will enable him to attend to his duty 
with promptness and willingness. Such an Examiner is valuable to 
any Company, and his services will not only be appreciated, but he 
will retain the good-will of the Agent without sacrificing in any way 



14 HOW TO EXAMINE FOR LIFE INSURANCE. 

his reputation with the Company ; and he will honestly discharge 
his duties, which demand that, in the short time that he is to be 
present with the applicant, he shall acquaint himself as thoroughly 
as possible with all that pertains to the individual. 

He should under no circumstances be forced to make any sort 
of an examination with any one present, or in a place where he is 
constantly interrupted. It is well for the Examiner to at once state 
to the applicant that he would like to make this examination under 
the most favorable auspices, not only for the benefit of his Com- 
pany, but also for the applicant himself, that he may state on his 
paper exactly his physical condition, and not be obliged to give the 
Company the benefit of doubts which arise from avoidable causes; 
and, possibly, the quieting influence which a little chat will have 
upon the applicant will tend to diminish a pulse-rate which would 
naturally be somewhat quickened by excitement or fear that some- 
thing is going to be discovered about him which will tend to shorten 
his life and of which he does not know. Sitting together and 
chatting for a few moments, discussing the family record and the 
statements made in the application, an Examiner, if he is observant, 
will be able to note various points about the applicant which are 
extremely important. The first impression that one gets of an 
individual is certainly a very valuable one, and should not fail to 
be noted on the examination paper : Does he appear to be a man 
who would indicate resistance to fatigue ? Does he look healthy, 
strong, etc. ? There are some individuals who, upon most careful 
examination, show nothing whatever the matter with them, but yet 
there is a something about them that impresses one that they will 
not be long-lived. Is this the case with the applicant before you ? 
Does he look as if he was a man whose occupation was more 
fatiguing than his degree of vitality would sustain ? Does he look 
as if he was worrying about his business affairs ? Does he look as 
if he took care of himself? Does he eat his meals quietly, and give 
his food time to digest ? 

It is this very impression, in one accustomed to making a num- 
ber of examinations, that is as important as his power to detect 
disease; and frequently, upon the closest examination, an Examiner 
will not be able to detect disease in an individual, yet he is impressed 
with the fact that the applicant has not a healthy appearance. It is 
the detection of this want of power of resistance to disease on the part 
of the applicant that constitutes the best class of medical examiners. 



THE EXAMINATION OF AN APPLICANT. 1 5 

Yet, on the other hand, one should be able to correctly describe 
the appearance of the applicant, and his reasons for his rejection of 
him, otherwise an Examiner might receive a false impression, and 
thus do an injustice to an applicant; a man who is exposed to the 
vicissitudes of climate may present an appearance which would cer- 
tainly go against him should personal appearance alone constitute 
the cause of his rejection, whereas in fact, he may be a perfectly 
healthy man, and the Examiner should be able to discriminate be- 
tween the rugged surface which has suffered on account of expo- 
sure or occupation, and that which is the result of poor vitality. Too 
rigid an examination is often brought up against an Examiner, and 
indeed we have found cases where the Examiner, impressed with 
the importance and necessity of a thorough picture of the case to 
the Home Office, has subjected the applicant to a too critical and 
annoying examination. An experienced Examiner should at once 
detect any evidence of disease on the part of the applicant, and if 
he finds a weak point, then it is his duty to follow it up as carefully 
as possible, but for an applicant, whose family record, occupation 
and previous history are good, to be subjected to a very rigid exam- 
ination, is not to be expected. It is not at all necessary, in ordinary 
cases, that the applicant should be stripped to the skin ; it simply 
suffices that care should be taken in auscultation and percussion, 
that no outside sound should reach the Examiner's ear, on account 
of starched shirt bosom or other clothing. 

In answer to your questions in regard to his habits of life, do his 
answers convey the impression that he is sleepless, that he carries 
his business troubles home with him, that, in fact, the load which he 
is carrying is greater than he can bear ? This is a very important 
matter, and one which affects a life risk possibly very much more 
than the few little lesions that may be discovered in the examina- 
tion, and which of themselves may not be considered important ; but 
far more important is the just appreciation of the strain, the wear 
and tear upon the system which the men of the present day are 
submitting themselves to. There are some who can stand it. They 
have received a momentum from a strong and healthy constitution 
which will carry them through life, notwithstanding the greatest 
possible strain, but by far the majority of the cases succumb to dis- 
ease before their expectation of life, according to the insurance 
tables, would expire. 

This quieting conversation, though it may be only for a few 



1 6 HOW TO EXAMINE FOR LIFE INSURANCE. 

moments, will enable the Examiner to correct statements which the 
applicant may have inadvertently made on the application, confirm 
the report generally, and enable him to state any important matters 
which would possibly require a special letter to the Home Office. 

When considering the family record, and conversing thereupon 
with the applicant, all such statements that are found upon the 
application as causing the death of parents, brothers or sisters, such 
as "childbirth," " debility," "pneumonia," etc., should be inquired 
into, and the exact disease from which the relative died should be 
noted, and an investigation made as to whether there are any cases 
of "phthisis," "gout," "apoplexy," "rheumatism," "kidney disease," 
etc., in the family or its collateral branches. It is surprising how 
many papers come to the Home Office of a Company with the word 
" Childbirth " as the cause of death, especially when you take into 
consideration the really small percentage of deaths in childbirth 
that actually occur. 

The various questions that appear upon the examination blank 
should then be answered. The answers to the questions should, as 
far as possible, be limited to "Yes" or " No; " it will be noted by 
a study of the blanks that the questions have been so arranged as to 
admit of a definite answer ; though, if thought advisable, a more 
elaborate reply should be made to clear up any doubtful points. 
These questions having been explained to the applicant and 
answered with deliberation, the Examiner should now prepare to 
make the physical examination. 

The examination should begin by a study of the applicant's 
appearance, the color of his eyes, his complexion ; does his skin 
show a healthy hue, are his eyes bright, does his face exhibit the 
characteristics of health, not drawn or haggard by disease or lined 
with wrinkles, which denotes premature ageing ; note the color of 
the hair ; and it is well also to examine the tongue and see whether 
there is any evidence by it of disease or disorder of the digestive 
tract; an examination of the tongue should also include an 
examination of the throat, and if anything is discovered in the way 
of ulcers, patches, chronic pharyngitis, enlargement of the tonsils, 
or any indications which point to cancer or syphilis, it should be 
noted. Is the eye bright and clear, or are the pupils contracted or 
unequal, or have they the appearance of sleepiness or drowsiness, 
which would denote the abuse of narcotics ; is the tongue thickly 
coated, the throat congested, the eyes somewhat bloodshot, which 



HABITS. 17 

would denote the excessive use of stimulants, and especially should 
this be noted if there is an odor to the breath ; there is a peculiar 
odor which is often found in drinkers, which is difficult to describe, 
but which I have frequently noted to resemble the odor which arises 
from a damp cellar. 

The applicant should be so placed in front of the Examiner that 
the light from the window should fall upon his face, and in that way 
the appearance of the skin can be noted ; not only should this be 
examined for the evidences of eruption but also for the cachexia of 
the various diseases, yellowness or anaemic condition of the skin, 
puffiness about the eyes, pallor or blueness of the lips, prominent 
cheek-bones with the hectic of phthisis. These are all considered 
very important. 

During the conversation, the Examiner can note the character of 
the applicant's voice, whether it is sonorous, sharp, high-pitched 
or husky, which are evidences of laryngeal phthisis ; and the 
rapidity of the breath should be taken. 



CHAPTER IV. 

HABITS. 



The question of the use of alcoholic stimulants has a very im- 
portant bearing on life insurance examinations. Insurance com- 
panies should endeavor, as far as possible, to select their lives from 
the average class of human beings. This not only refers to age 
and occupation, but it also refers to individual habits, heredity and 
possibly even temperament. Statistics show that the mortality is 
less in England, among the moderate drinkers, than among the 
teetotalers, and this undoubtedly can be explained by the fact that 
moderate drinkers form the largest class of the population, and 
that possibly their moderation in this line is an index to their mod- 
eration in other things, and it brings them under the class of the 
least mortality. There is undoubtedly the greatest difficulty in 
judging of the exact amount of alcohol which an individual takes. 
There is no more difficult problem to solve in the whole of insur- 



1 8 HOW TO EXAMINE FOR LIFE INSURANCE. 

ance than to know what moderate drinking is. Shall we take his 
own opinion, or the opinion of the examiner, or the general reputa- 
tion that the applicant has among his neighbors ? Where the least 
suspicion exists as to the abuse of alcoholic liquors, the Examiner 
should first carefully investigate the effect they have had upon the 
system of the applicant. Do his functions normally perform their 
duties ? Is his skin bright and clear, or mottled and congested ? 
Are there any evidences of bilious derangement — coated tongue — 
nervous disturbance ? These are most important. Then the 
question as to the amount that the applicant acknowledges indulg- 
ing in and the character of his beverages should be considered. 
Does he drink between meals ? Does he drink in the morning ? 
An insurance company would always be safer to refuse a policy to 
one who acknowledges drinking before breakfast, as such an indi- 
vidual is certain to be classed among the intemperate. 

" Intemperance is, perhaps, the most formidable enemy to the 
safe insurance of lives. It ranks before phthisis in its deadly effects 
on the human system. Not only is it often inherited, but organic 
ailments are by it originated and organic weakness crystallized into 
disease. The tendency to disease — as phthisis, gout, rheumatism 
and diabetes — are by it converted into actualities. Its slow, insidi- 
ous effects upon organs in hardening their connective tissue, and 
thereby contracting as by a band on their blood vessels and choking 
off their supply of blood, are exemplified in cirrhosis of the liver, 
but act also on the lung and kidney. By promoting the fatty 
degeneration of muscular tissue in the heart and the whole system 
of arteries, and favoring sclerotic changes in their coats, the circu- 
lation from its centre to its ultimately terminating branches is 
affected, and either by failure of the heart itself, or by depriving the 
vessels of their elasticity and contractile power and favoring athero- 
matous changes in their coats, which lead to rupture and hemor- 
rhages, it becomes a deadly agent. The vessels of the brain are 
sure to be involved and apoplexy rendered most likely. The 
degenerations of age are anticipated and precipitated by alcohol, 
and the dram drinker is thus sure to have a shortened life. 

" The primary effects of alcohol on the nervous system — from 
nervous disorders, from various disorders of motion and sensation 
up to delirium tremens — are among the earliest but not the most 
fatal of its results ; and the organic alterations which we have indi- 
cated are found rather in the dram drinker than in the drunkard. 



HABITS. 19 

It is the man who carries his drink well and is always under its 
influence who is in greatest danger. We must, therefore, decline 
to attach any value to the statements of an applicant or his friends 
that he ' Never was known to be drunk.' Small doses of stimu- 
lants taken repeatedly through the day and ended in a somewhat 
larger one at night, leave the system charged with alcohol, from 
which it is, in fact, never free, and the excretory organs are there- 
fore continuously under its influence. These are the most danger- 
ous cases, and therefore the Medical Examiner should not rest 
satisfied with the reply, ' I have never been drunk in my life.' The 
most searching inquiry should be made, with all the tact of the 
physician, as to the quantity taken each day and the frequency of 
the dose. We may forgive the rare outbreak of the youthful on 
certain festive occasions, if we are satisfied that the habit of drink- 
ing in the day hours has not been acquired, but we cannot pass the 
applicant whose daily habit is to take stimulants three or four times 
in the twelve hours. Drinking between meals should always be 
inquired about in cases in which we have any doubt about habits. 

" The evidence of friends about temperance is often of the most 
unreliable nature. Each man has his own measure of what consti- 
tutes ' temperance ' or what may be called excess. 

" When evidence as to ' moderation ' is required the replies are 
often most unsatisfactory, and have frequently to be wrung out of a 
1 friend ' by repeated correspondence as to what the habits of an 
applicant really are. Medical officers are well aware that this is the 
most troublesome part of their duties, and that finally even the most 
elaborate correspondence will fail to clear up the point to the satis- 
faction of the Board or the Examiner. In such cases we are 
inclined to give the Company the benefit of the doubt. 

" In studying the facts of intemperance, we may distinguish the 
following classes of victims : — 

" The dram drinker, of whom we have already spoken. 

" The occasional drunkard, who may get drunk at a fair or festivity 
several times a year, being temperate in the interval. This is very 
common in the country. 

" The man who has violent outbreaks of intemperance at long in- 
tervals, which may last a week or a month, and then, under the influ- 
ence of duties to be performed, or fear of dismissal from office, or 
other powerful cause endangering his position in life, subsides into 
temperance or total abstinence. 



20 HOW TO EXAMINE FOR LIFE INSURANCE. 

11 For none of these can we find a place in Life Insurance. All of 
them are among the most dangerous risks which are offered to a 
Company; and no money consideration can be put against the 
chances of such a life breaking up suddenly."* 

The use of narcotic drugs comes also under consideration, and 
should be most carefully inquired into. 



CHAPTER V. 

THE PULSE. 



It is well, after conversing with the applicant about his family 
record, etc., to at once take the pulse rate and rate of respiration. 
The importance of doing this before proceeding with the ordinary 
examination of the applicant is evident to all who examine for 
life insurance. The pulse would naturally be increased in force 
and frequency by any excitement, as well as by disease, and it is 
often impossible to make a correct interpretation of the cause 
of its frequency or to differentiate the rapid pulse of excitement 
from the rapid pulse of a diseased heart or incipient pulmonary 
disease. Should the Examiner find a pulse too rapid he should re- 
quire the applicant to sit for a while, engage him in conversation, and 
after a short time note again the pulse rate and its rhythm and the 
character of the artery. It is always well to take the pulse rate for 
a full minute by the watch, and also to take the rate of both the 
right and left radials. The hands should rest at ease on a table, 
so as not to produce any excessive strain upon the artery; the 
attention of the applicant should be called to other matters while 
the pulse is being taken. The pulse, as a rule, is indicative of the 
condition of the heart, but at times, owing to the atheromatous 
condition of the vessels, the pulse wave may distinctly differ from 
the cardiac impulses. A slight intermittency may be noted in the 
pulse, which would escape one's attention upon the examination of 
the heart. 

* Pollock and Chisholm's Medical Handbook of Life Assurance. 



THE PULSE. 21 

The finger should be gently placed upon the artery, the degree 
of resistance noted, the presence or absence of atheromatous 
patches or rings, and the pulse studied for its rapidity, intensity, 
regularity and intermittency. The normal pulse rate in the male 
varies from 70 to 72, in the female about 80. Atheroma, of course, 
should be looked for as age advances. 

THE SPHYGMOGRAPH. 

This is an instrument which registers the qualities of the pulse 
by means of tracings. It has by no means become universal in 
life insurance examinations, owing to the fact that the instruments 
are expensive and the tracings difficult to take. In doubtful cases, 
for large amounts of insurance, if the Examiner is thoroughly posted 
in the use of the sphygmograph, tracings made when the applicant 

Fig. i. 




Sphygmogram of radial artery ; pressure 2 5. Each part of the curve between the base of the up- 
stroke and the base of the next up-stroke corresponds to a beat of the heart. This figure shows 
five heart-beats and the part of a sixth. 1. Line of ascent, a to b. 2. The apex, b. 3. The line 
of descent, b to h. 

is free from excitement and the pulse in its normal condition would 
add value to the record of the examination. 

The sphygmograph is valuable not only in cases that are ren- 
dered doubtful by a suspicion of a disease of the artery, but also 
in the detection of affections of the heart, as it indicates the degree 
and tension by increased pressure in the arterial system caused by 
ventricular systole. 

The pulse tracings consist of a series of curves, each of which 
corresponds with one beat of the heart.* 

The line of ascent is nearly vertical and corresponds to the dilata- 
tion of the artery, produced by the systole of the left ventricle. 
In cases of aortic regurgitation it is quite vertical. The apices of 
the normal pulse are pointed. 

The line of descent is gradual and corresponds to the contraction 

* Landois' Physiology. 



22 



HOW TO EXAMINE FOR LIFE INSURANCE. 



of the aorta. In this line will be noted two distinct elevations, the 
most marked/, the dicrotic wave, corresponds to the closure of the 



Fig. 2. 




Aortic regurgitation. 



aortic valves; the tidal wave, d, is the one preceding this, and is 
well marked in cirrhotic disease of the kidneys, accompanied by 



Fig. 3. 




Irregular pulse of mitral regurgitation. 



hypertrophy of the left ventricle. The dicrotic wave is absent or 
slightly marked in cases of atheroma or any aortic regurgitation 



Fig. 4- 



Aortic stenosis, probably congenital. Male, 19 years. (Jaccoud.) 

(Fig. 2). In mitral regurgitation the tidal or pre-dicrotic wave may 
be absent in some beats, but present in others, as seen in (Fig. 3). 

Fig. 5. 




Irregular pulse, with mitral stenosis. (Schenle.) 



IRREGULARITY AND INTERMITTENCY. 

Irregularity in the pulse differs from intermittency, and this 
should always be noted. By irregularity we mean inequality in the 



HEIGHT AND WEIGHT. 23 

pulse beat, both as regards force and as regards frequency. By 
intcrmittency we mean the actual dropping of a beat. It may be 
rhythmical, occurring so many to the minute, or may be irregular 
in frequency. In some persons regular intermittency has occurred 
from childhood, and is supposed by many to be in certain cases 
normal to the individual. But irregularity is usually an evidence 
of some cardiac disturbance, which requires either postponement 
of the applicant for future examination, or absolute rejection if it 
is found associated with evidences of heart disease. 



CHAPTER VI. 

HEIGHT AND WEIGHT. 



It is a curious thing how few people know their own height, and, 
indeed, how few know their own weight ; and as the question of 
height and weight, as far as their relation exists to one another, is an 
important matter in the decision of a case, and, also, as the height 
is frequently of very great importance when considering the death 
claim, if any mystery surround the case, the figures that an Exam- 
iner gives should be as correct as possible ; every applicant's height 
should be measured, and this is a very easy thing to do by means 
of an ordinary tape measure, requesting the applicant to stand his 
heels firmly against a flat wall surface, and marking with a pencil 
his height, or the Examiner should have already in his office a scale, 
or a mark on some convenient wall, so that he can take these 
measurements in a few moments, and it is customary to consider 
the applicant's height with his shoes on. 

The matter of weight becomes also at times of very great im- 
portance, especially when we consider the under-weights and over- 
weights. In order to avoid the expense of an unnecessary medical 
examination, many Companies furnish their Agents with a table of 
heights and weights, the understanding being that this table only 
shows the average at a certain age, and that a certain per cent, over 
that is allowable for over-weights, and under it for under-weights, 



24 HOW TO EXAMINE FOR LIFE INSURANCE. 

but we all know how impossible it is, in the selection of lives, to 
confine ourselves entirely to these table measurements ; there are 
those who have a very thick-set, muscular form, in good proportion 
so far as the trunk goes, but with legs that are disproportionate; 
then, again, a man may have good chest measurements, and exceed 
in height, and be ranked as an under-weight, when in reality his 
looks do not class him as such. 

The measurements of the chest and abdomen are very important 
indications of over- or under-weights ; a man with a narrow chest 
is less desirable as an under-weight than a man whose chest is in 
proportion, just as one who has an abdominal circumference greater 
than his chest is a less desirable risk as an over-weight, than one 
who has a very heavy deposit of muscles on his trunk and arms. 
These points should always be noted on an examination blank. In 
cases of over-weight where the Examiner feels sure that the appli- 
cant is above the tables that are usually adopted by the Company 
for which he examines, he should make it a point to get the accu- 
rate weight by asking the applicant to step with him to the nearest 
drug or grocery store, or any place where there are scales, and thus 
save himself the trouble of doing this afterward, at a more inconve- 
nient time, upon request from the Home Office. 

PROPORTION BETWEEN HEIGHT AND WEIGHT OF HEALTHY MEN. 
(Dr. Robertson's, Abridged.) 



Height. 


Weight. 


Weight- 1 


Weight + \. 


Height. 


Weight. 


Weight -I 


Weight + ^ 


Ft. In. 


Bbs. 


fi>s. 


lbs. 


Ft. In. 


fi>s. 


lbs. 


ft)S. 


5 3 


125 


IOO 


I50 


5 9 


164 


131 


197 


5 4 


131 


I05 


157 


5 10 


172 


138 


206 


5 5 


137 


no 


164 


5 11 


179 


143 


215 


5 6 


144 


115 


173 


6 


187 


I50 


• 224 


5 7 


150 


I20 


ISO 


6 1 


I96 


156 


234 


5 8 


157 


126 


1 88 


6 2 


203 


163 


243 



The weights given in the accompanying table were taken from 
the average of adults of middle life, set. about 30, and the variation 
allowed (one-fifth, or 20 per cent.) would cover fairly the lighter 
weight of younger persons, down to set. 20. 

So long as the one-fifth — or -f is not exceeded, the variation 
from the standard weight need not tell against the life ; but if the 
weight is less than four-fifths of the average, or if it exceeds the 
average by more than one-fifth, then it may tell against eligibility 
of the life — each case being judged on its own merits. If in any 



EXAMINATION OF THE HEART. 2 5 

case the weight is too low, and the family history shows a tendency 
to consumption, such a life ought not to be accepted as a first-class 
risk, and the same applies to excessive weight where there is a 
quick pulse or a weak heart. 



CHAPTER VII. 

EXAMINATION OF THE HEART. 



We have placed the examination of the heart before the general 
examination of the chest of the applicant, in order to be sure that 
we will obtain as clearly as possible an insight into its normal con- 
dition before the examination of the lungs, which would have a 
natural tendency to excite the circulation. 

Many Life Insurance Examiners, in their haste, owing to lack of 
time, are more apt to make the physical examination of the lungs 
precede the minute examination of the heart, and thereby, by 
forcible expiration and inspiration, excite the applicant and increase 
the force of his circulation, and the result is, that when the ear of 
the Examiner is placed to the chest wall, the heart sounds are 
abnormally increased in intensity and the pulse is quickened. It 
would be impossible to directly pronounce the existence of a 
murmur, or to differentiate the normal exaggerated sounds from 
those that are produced by disease. 

The methods used in the examination of the heart are : inspec- 
tion, palpation, percussion and auscultation. 

Position of the Heart in the Chest Wall. — The most certain, and, also, 
the most rapid method of counting the ribs and spaces, say on the left 
side, is to place the palm of the left hand on the sternum, and keep- 
ing the little finger in the first intercostal space, run the other 
fingers down the corresponding spaces till the thumb is placed on 
the fifth, in which we shall find the normal inferior limit of the heart 
itself. 

The apex beat at once arrests our attention. From every stand- 
point it is the most conspicuous, the most significant, and, in the 
normal condition, the most constant feature of cardiac physiognomy. 



26 HOW TO EXAMINE FOR LIFE INSURANCE. 

It is the key to the position of the heart. It tells us most readily 
of the disturbing forces that are attacking the heart, either from 
within or from without, for while the base is the most fixed, the apex 
is the most free to move or to be moved in any direction. 

Position of the Apex Beat. — Normally, it is situated in the fifth 
intercostal space, or just behind the upper border of the sixth rib 
on the left side. It should be a little further below the nipple than 
it is within the vertical nipple line, or about I y^ inches below and 
Y^ of an inch to the right of the nipple, for it will be remembered 
that the nipple does not occupy a fixed point. The beat extends over 
an area of about an inch square,, and it is formed, in the main, by a 
small portion of the left ventricle. 

If the apex beat is rather diffused, then the point of pulsation 
furthest to the left is to be regarded as the apex. The person 
lying on the left side the apex is brought nearer the chest wall, 
and the impulse made more distinct ; and it is at the same time 
carried a very little toward the left. We therefore move the appli- 
cant on to his left side if the beat is faint or imperceptible in the 
erect or dorsal positions, and if still in doubt, we endeavor to 
ascertain its position by auscultation. The apex beat terminates 
the long axis of the heart, the long axis itself being directed down- 
ward, slightly forward, and markedly to the left. 

The Base of the Heart. — This measures about three inches, and is 
pretty equally divided by the middle line. Being at right angles to 
the long axis, it looks, not directly upward, but somewhat to the 
right, so that the left auricle is the higher of the two. It reaches 
almost to the lower edge of the second left costal cartilage. 

The left border of the heart will be pretty accurately followed by 
drawing, from the left extremity of the base line, a line convex out- 
ward so as to almost touch the nipple, and then curving it slightly 
inward to the apex. (See Plate No. 3.) The right border cannot 
be so definitely sketched, as the heart rounds gradually backward, 
but the furthest point to the right is about midway between the 
mesial and right nipple lines, or an inch fully to the right of the 
sternum. The inferior border of the heart ascends with but a slight 
departure from the horizontal to join the right border. The above 
may be taken as the normal outline of the heart, always remem- 
bering that the apex beat is the only point that we are able actually, 
that is clinically, to fix. 

Inspection. — We would refer the reader to the subject of the 



PLATE II 




Topographical survey of Front of theBody of an Adult Male, showing Accurate Relations of the Viscera 
of the Thorax and Abdomen in proximity to the Diaphragm, in Tranquil Breathing. 



Apex of right lung. 

Supra-sternal notch. 

Junction of second costal cartilage with stern- 
um. (Seat of aortic murmurs.) 

Seat of aortic valve. 

Right auricle (tricuspid murmurs). 

Upp-r border of liver and line of diaphragm. 

Lower border of liver. 

Apex of left lung. 

Upper border of junction of third costal carti- 
lage with sternum and pulmonary artery. 

Valve of pulmonary artery. (Seat of murmur 
in pulmonary artery.) 



val> 



(Seat of mitral 



ti. Left auricle Mitral 

presystolic murmur.) 
t2. Left nipple. 
[3. Apex of heart. (Seat of mitral regur| 

murmur, transmitted from 11.) 
[4. Line of diaphragm. 
t 5 . Pylorus. 
i6. Stomach. 
[7. Umbilicus. 

18. Lower border of pulmonary resonance, 
tg. " " of left lung. 



EXAMINATION OF THE HEART. 2J 

general inspection of the chest, in Chapter VIII. In health, on in- 
spection of the heart, we find that there is no precordial bulging of 
the chest wall. In the dorsal decubitus, the impulse, if visible at all, 
is confined to the apex beat, unless the applicant be of spare build, 
when it may be seen, also, in the space above; there is, practically, 
never epigastric pulsation. 

Deviations from this are, first : The bulging of the precordial 
region by valvular disease, which has produced a change in the 
character of the chest wall. 

$econd. The area of impulse may be increased by increased 
action of the heart, due to physical or mental excitement. This 
can be readily ascertained as the cause by noting the normal 
position of the heart and its freedom from valvular disease, and by 
permitting the applicant to rest quietly for a time before a second 
examination is made. It must also be borne in mind that the abuse 
of tobacco or of stimulants is also an exciting cause. 

Third. The area of impulse may be increased by hypertrophy or 
dilatation of the heart. 

Fourth. The area of impulse is diminished by anything that will 
diminish the cardiac action, or by an emphysematous lung, over- 
lapping of the heart, pleuritic effusions or by pericardial effusions. 

Fifth. The area of impulse may be displaced by pleuritic effu- 
sions or pleuritic adhesions, by pneumothorax and aneurisms of 
the aorta and pericardial effusion. 

Palpation. — In the examination. of the heart, inspection and pal- 
pation go hand in hand. The one supplements, and it may be 
corrects, the other. We try again if the beat is sharp or prolonged, 
punctate or diffuse. But palpation does more ; it tests the force 
of the impulse, and we also feel if there is anything like a thrill 
or vibration conveyed to the chest wall. This impulse marks the 
beginning of the ventricular systole, a fact that, as we shall see, 
may be of great value in verifying the rhythm of the cardiac murmur. 
The ventricular contraction is synchronous on both sides ; it is a 
movement toward the chest wall, and also downward, with a slight 
wave from left to right. 

In disease, the impulse force may be increased by anything that 
will increase the force of the heart's action, as hypertrophy alone or 
with slight dilatation. 

Percussion. — The percussion of the heart is hardly of the same 
character as that of the lung. It is not so much to test the indi- 



28 HOW TO EXAMINE FOR LIFE INSURANCE. 

vidual part as to mark the outline of the whole, and this is not so 
easy. From all sides, the lung flows and ebbs on its surface with 
every act of inspiration, and while one form of pulmonary disease 
may leave the heart unduly exposed, another may completely cover 
it in. Nor does the heart present a flat surface for examination, but 
one which has a strong convex curve transversely as the heart 
rounds deeply within the chest. These conditions once more 
demand a constant study of the normal heart, to which the follow- 
ing directions can at best be only a guide. Two areas must be 
carefully distinguished — the exposed surface of the heart and the 
parts overlapped by the lung. 

The Exposed Area of the Heart. — This consists practically of the 
right ventricle, the apex being the only part of the left ventricle 
that comes round to the front. It is somewhat triangular, and 
extends upward to the level of the upper margin of the fourth costal 
cartilage in the middle line ; thence its right border falls perpen- 
dicularly — that is, down the middle line, while the left runs straight 
to the apex. The base coincides with the inferior border of the 
heart as far to the right as the middle line. This forms the area of 
superficial or absolute dullness. Obviously, it is affected by respi- 
ration ; by forced inspiration the heart may be largely covered by 
the lung. (See Plate No. 3.) The area we have been assuming, 
and have just described, is that of moderate inspiration. Under 
ordinary circumstances the actual dullness hardly extends to the 
middle line, on account of the percussion vibrations of the sternum 
itself. This could be in part corrected by making the applicant 
incline inconveniently forward, thus bringing the heart in closer 
contact with the chest wall. 

The Lung-covered Surface of the Heart. — This forms the area of 
deep or comparative dullness. Here there are insuperable difficul- 
ties in the way of accurate demarcation. The heart rapidly recedes 
on the right side under the sternum, which yields its own note of 
percussion. To the lower right there is hepatic dullness, with which 
that of the heart is continuous. Sometimes a distinction, sometimes 
an actual break, in the character of the dullness can be made out 
by experts, although the discrimination is possibly materially aided 
by knowing that a line drawn along the upper margin of hepatic 
dullness to the apex of the heart will traverse the cardiac boundary. 

Area of Cardiac Dullness. — It is most important that this should 
be accurately determined, especially in cases where there is in- 



EXAMINATION OF THE HEART. 20, 

creased heart action from nervousness, tobacco, alcoholic or coffee 
abuse, etc. Increased area of cardiac dullness may seem to exist 
from anything that will retract the lung-, or from pericardial effu- 
sion. It may actually exist from hypertrophy and dilatation. 

Auscultation. — The auscultation of the heart is a most important 
part of an examination for life insurance. So exact, so elaborate, 
so refined has it grown that the Examiner always approaches it with 
misgiving. Here, again, there is but one way — first, to study the 
normal state, then the grosser departures from health, and then the 
intricacies of finer and more subtle disorders. . And so, beginning 
with the healthy phenomena, we consider first — 

Cardiac Sounds. — Each beat of the heart, as we all know, is 
made up of two sounds followed by a pause ; this complete revo- 
lution is usually termed the cardiac cycle. The two sounds are 
evidently not alike. The first is prolonged, with more volume, yet 
duller; the second is short and sharp. The word " lubb-tupp" is 
usually selected to imitate them. Wherever the sounds are heard, it 
will be noticed that as regards quantity, the first sound is always 
long and the second always short; but it is not so as regards accent. 
With a little care the accent can be made out to be on the first 
sound at the apex, while at the base it is on the second sound. The 
first sound is coincident with the beginning of the ventricular sys- 
tole, the second sound with the beginning of the ventricular dias- 
tole, while during the pause, or perhaps only toward the end of the 
pause, the auricles are silently contracting. 

The relative duration of the different periods within the cardiac 
cycle cannot be exactly estimated. In the case of the normally 
beating heart, the pause is longer than either the ventricular sys- 
tole or diastole, but hardly as long as the two combined. The 
diastole is shorter than the systole. The auricular systole is gener- 
ally believed to occupy a very short period immediately before the 
first sound. If the heart's action is quickened, it is chiefly the 
period of rest that is shortened. {Anderson}) As to the valvular 
elements in the sounds, it is generally agreed at what points the 
different parts of the sound produced at each orifice can be heard. 
But, again, the Examiner will remind himself of their anatomical 
situation. A line drawn from the upper border of the third left 
sterno-costal articulation to the fourth right intercostal space will 
cross the pulmonary aortic, mitral and tricuspid orifices in the 
order named ; a superficial area of half an inch square and the 



30 HOW TO EXAMINE FOR LIFE INSURANCE. 

bell of a stethoscope will cover all four. (Walshe) But it is not 
here that we listen to the sound of each orifice. Overlapped by 
lung and lying at various depths in the thorax, their sounds are 
conducted to very different points on the chest wall : mitral sounds 
are sought for at the apex ; those of the tricuspid valve at the lower 
end of the sternum ; the aortic in the second right and the pulmonary 
in the second left intercostal space close to the sternum. (See Plate 
No. 3.) 

Alterations may take place in the heart sounds, first, by anything 
that weakens the heart's action. Second, on account of an interven- 
ing medium which lessens their conduction, as an excess of fat or 
muscle in the chest wall and pericardial effusion. Third, both sounds 
may be mcreased by nervous excitement, especially in young people. 
Fourth, by hypertrophy, though in the latter the first sound is 
usually said to have a muffled quality, but conveying the idea of 
increased volume, a short, sharp, clear first sound indicates dilata- 
tion. Fifth, alterations may take place in the heart sounds in char- 
acter, as reduplication, by which is meant a doubling of one sound 
or both, and may be consistent with health, though, as it is usu- 
ally the second sound which is doubled; it also occurs with mitral 
disease and with disease of the lung, and on that account it is diffi- 
cult to absolutely disassociate its presence from that of disease, and 
it is considered to be sufficient cause for the rejection of the appli- 
cant. The doubling of the first sound is supposed usually to be 
found in connection with cardiac hypertrophy from cirrhosis of the 
kidney, though it is said that at times it is found independent of 
disease; nevertheless, the former being more frequent, it should be 
taken into consideration in Life Insurance examinations, and is suffi- 
cient cause for rejection. Sixth, the metallic quality of the sounds. 
This is usually produced by the presence of a neighboring cavity 
or by pneumothorax, though it may be produced by a distended 
stomach ; careful examination of the lung will at once show 
whether pneumothorax is present, and, of course, if the metallic 
quality is produced by a distended stomach and no other evidence 
of cardiac disease, the fact should be noted on the papers. 

Cardiac Murmurs. — A cardiac murmur is a sound which may be 
added to or may supplant the ordinary cardiac sound. There are 
various degrees of intensity, and their presence or absence is an 
important feature to be decided. They may be endocardial and 
pericardial. Endocardial murmurs are called organic murmurs if 



EXAMINATION OF THE HEART. 3 I 

they are produced by any organic or structural change in the heart 
or in its valves, or by anything that interferes with the passage of 
blood through the heart. Murmurs are usually studied according to 
their rhythm, by which we mean the relation of the murmur to one 
or the other of the heart sounds. They are also studied according 
to their locality, by which we mean their point of greatest intensity. 

An Examiner for Life Insurance should first of all be able to 
detect the presence of a murmur, that is to say, he should be familiar 
enough with the heart sounds in health to note whether or not a 
murmur exists in the Applicant under examination. Having 
decided positively that a murmur does exist, his next step should 
be to ascertain its rhythm, whether it is presystolic, systolic or 
diastolic. Having decided on this point, he should now study the 
seat of the murmur, its transmission and conduction; w r hether it is 
heard over the aortic area, the pulmonary area, the tricuspid area 
(ensiform cartilage), the mitral area (the apex), and whether it is 
audible in the back. 

'Having definitely settled this matter in his mind, he should then 
study the character of the murmur, whether it is soft or blowing, 
harsh or rough. Taken into consideration with his study of the 
heart in relation to its size and the character of the circulation, the 
question comes up whether the murmur is functional (anaemic) or 
organic ; though these points should be noted on the examination 
blank for the sake of thoroughness, their relation to the insurability 
of the applicant is a question that rests entirely with the Home 
Office ; and though probably the question " Is longevity affected 
by functional disorders of the heart ? " is one that will be settled 
at some future time, the general opinion at a majority of the Home 
Offices to-day is not to grant insurance without a very decided extra 
to any one who has any form of cardiac disease, whether functional 
or organic, if at all. 

Pericardial Murmurs. — These are all evidences of disease, as the 
normal pericardium, like the pleura, is soft and smooth, and its two 
surfaces act upon one another perfectly noiselessly. Pericardial 
murmurs are heard usually over the body or exposed surface of the 
heart and are not transmitted. They are differentiated from pleural 
friction by their ceasing when the applicant holds his breath ; but if 
pleurisy exists upon that surface of the pleura which is in contact 
with the pericardium, the friction may continue synchronous with 
the heart's action. 



32 HOW TO EXAMINE FOR LIFE INSURANCE. 

Murmurs are frequently heard, that are functional, over the 
arterial tracts, and these may be due, besides anaemia, to pressure 
from tumors or enlarged glands, or consolidated lung tissue, or the 
pressure of the stethoscope. 

Venous pulsations are sometimes distinctly noted, and are usually 
the result of cardiac disease. Venous murmurs may be heard chiefly 
in the external jugular, and they are associated with anaemia. They 
are heard usually in women, more marked on the right side when 
the applicant is erect. Venous murmurs, being the evidences of 
anaemia, would disqualify one for life insurance for the time being. 

A murmur heard at the base may accompany the first sound and 
may be either functional or organic, afunctional, the murmur may 
have a feeble, soft quality, may be variable in intensity and may be 
heard more especially over the pulmonary area, but it may be heard 
over the aortic area and carried upwards to the vessels of the neck. 
Pulmonary systolic murmurs (heard close to the left of the sternum 
between the second and third ribs) are the most frequent of cardiac 
murmurs. 

If organic it may be systolic, or diastolic and heard over the 
aortic area, and is dependent upon either aortic stenosis or regur- 
gitation, or both. 

A murmur, if heard at the apex, may be either pre-systolic or 
systolic ; if the former it precedes and does not displace the first 
sound, is rough and purring, is not conducted, and is but rarely 
heard in the back ; it is due to mitral stenosis. 

If systolic it is usually carried toward the nipple line, is most 
intense at the apex, and is carried beyond it into the axillary region 
and even conducted to the back, and heard below the angle of the 
scapula, or upwards along the vertebral column ; this is due to 
mitral regurgitation, owing to imperfect closure of the mitral valve 
from organic disease or functional disability. 

The tricuspid murmur which is heard over the exposed portion 
of the right ventricle, is transmitted downwards, and is usually sys- 
tolic, and due to tricuspid regurgitation. 

Organic murmurs are usually accompanied by changes in the 
size of the heart, whereas functional or anaemic murmurs are asso- 
ciated with anaemia. 

When murmurs are heard they should be definitely located by the 
Examiner, and he should state in his report whether there are 
associated with them any concomitant evidences of heart disease 



EXAMINATION OF THE CHEST. 33 

or anaemia. The case will probably be either rejected or postponed 
by the Home Office. 

There is one matter which is very important for the Examiner to 
remember, and that is that there are structural alterations in the 
heart, such as hypertrophy, with fatty degeneration, fatty infiltra- 
tions, tumors, and possibly diseases of enervation that are fatal, but 
these may be unaccompanied by any murmur whatever, though, of 
course, they are made evident by alterations in the sounds and other 
symptoms that denote heart disease. 

Again, the presence of a murmur is not always indicative of dis- 
ease of the heart, and an Applicant should not be at once rejected 
because the Examiner hears a heart murmur upon one examina- 
tion ; he should be postponed for a time, until satisfactory evidence 
of disease is found, as the case may be one of simple anaemia, loss 
of tone, or a purely functional disturbance. A functional murmur 
may disappear by a change of attitude of the individual, or an 
organic murmur be developed by exercise. 



CHAPTER VIII. 

EXAMINATION OF THE CHEST. 



The obtaining of the chest measurements demands a degree of 
care that -is rarely given to it. There is a certain knack in 
chest expansion which some people have, especially athletes; and 
it is impossible to get some men to expand their chest more than 
an inch, simply because they do not know how to do it, and not 
because they do not get sufficient air into their lungs. Again, 
some men will readily expand their chest three, four, or five inches; 
in fact I have seen them do it as much as six by straining them- 
selves, throwing their chest forward and drawing in the belly; then, 
again, we frequently note in some cases of marked lung impair- 
ment the chest measurements will show a difference between expi- 
ration and inspiration of three inches, which is considered to be 
about the normal. 

To take the chest measurements the applicant should remove the 
3 



34 HOW TO EXAMINE FOR LIFE INSURANCE. 

coat and vest and the chest should be free from any restriction ; he 
should stand erect and the tape-measure should be placed over a 
spot corresponding to the third costo-sternal junction and directly 
over the prominent portion of the scapula behind ; the applicant 
should then stand with his heels together, his hands at his side, 
and be asked to take a long, deep breath with his mouth open, and 
at the same time drawing in the belly ; he should then allow all the 
air to go out of his chest — force it out, and after doing this two 
or three times the measurements can be taken. 

The tape-measure should then be placed over the abdomen, on 
about a line with the umbilicus ; the applicant should fairly fill his 
lungs and the measurement of the abdomen should be taken. 

Women should be as carefully and as thoroughly examined as 
men, and for this purpose the chest measurements should be taken 
over the loose clothing without corsets. It should be borne in 
mind that the tape measure should be placed at about the third 
costo-sternal junction, so as to avoid the prominence of the mam- 
mary glands, and that the measurements should be taken of the 
waist above the hips, on about a line with the umbilicus. The 
waist measurement is what is wanted, and not what is usually 
misnamed the abdominal girth. 

Inspection. — In inspection we note the form and movements of 
the chest. The adult chest is elliptical in form ; it is not absolutely 
symmetrical, owing to the fact that the right side of the body is 
usually more used than the left. Upon inspiration, it tends to be- 
come circular. The Examiner standing before the applicant, he 
should note the size of the chest, and the number of respirations 
should be counted ; the average in the adult varies from 16 to 24 
per minute, making a ratio with the pulse of four beats to each 
respiration. The upper portion of the chest should be well filled 
during each inspiratory movement, and the movements in a healthy 
individual should be free from force ; the inspiratory movement 
slightly more prolonged than the expiratory. All portions of the 
chest should expand symmetrically, as the opposite would denote 
pleuritic adhesion, or the presence of solidification, or fluid in the 
chest. Inspection is a very important matter in the examination of 
an applicant for insurance, as it at once gives the Examiner a cor- 
rect idea of the performance of the vital functions of the heart and 
lungs, the location of the apex beat, the proper shape of the pre- 
cordial region, the usual attitude of the applicant, and the general 



EXAMINATION OF THE CHEST. 35 

degree of vitality. The experienced Examiner can, from inspection 
alone, readily see if there is anything that needs further investi- 
gation. 

Deformities of the Chest. — The deformities of the chest are of two 
kinds, bilateral and unilateral. The bilateral deformities are: the 
pigeon breast, the rickety chest, the chest transversely furrowed, 
the alar or pterygoid chest, and the emphysematous chest. The 
two latter are extremely important in Life Insurance examinations; 
the alar or pterygoid chest being recognized as the chest of phthisis, 
and the emphysematous chest an enlargement due to the emphy- 
sematous condition of the lung. 

The unilateral deformities of the chest may be divided into two 
classes, enlargements and contractions ; these are considered else- 
where. They should always be noted on the examination paper, 
for they become very important in regard to their effect on the 
probable future of the applicant. 

Expansion of the Chest. — By a careful measurement with the tape- 
line, in strong men the circumference of the chest is 34^5- inches, 
in females 32 inches ; the average expansion will increase it about 
-^ or three inches. It certainly should not be less than this, 
unless there is something wrong with the respiration ; but it 
may be found, should the expansion be less than the average, that 
the applicant does not know how to force the air out of his 
lungs. 

Increased Respiration. — The rate of respiration may be increased 
by muscular exertion, by disease of the lung, by pleurisy, by fever, 
by heart disease, by tumors in the abdominal cavity, in fact, by any- 
thing that will cause an extra demand for air. In cases of anaemia, 
the applicant will be short breathed ; and it frequently is an evi- 
dence of disease of the brain in its lower portion. 

Diminished Re spi?'ation. — The respiratory rate maybe diminished 
by mechanical obstructions, by injury to the brain. These will 
give rise to bilateral changes ; but unilateral changes may be due 
to local causes, as phthisical apices, pleuritic effusions, pneumo- 
thorax, etc. 

The respiratory rate may become irregular, through paralysis, 
disease of the brain or cord. If an abnormality exists in the 
respiratory movement, the applicant is for the time being unin- 
surable, unless it be due to a purely functional cause, when a post- 
ponement of the case will be necessary. 



36 HOW TO EXAMINE FOR LIFE INSURANCE. 

CHAPTER IX. 

EXAMINATION OF THE LUNGS. 

In the examination of the lungs we use precisely the same 
methods as we do in the examination of the heart — inspection, pal- 
pation, percussion and auscultation. 

Inspection. — We would refer the reader to Chapter VIII, on the 
inspection of the chest. 

Palpation. — By palpation we mean the applying of the palmar 
surface of the finger or of the hand to the chest wall for a study of 
the vibrations of the viscera beneath and the detection of any 
abnormality therein existing. 

The sensation transmitted to the finger will denote the character 
of the tissue through which the vibration passes, and by it will be 
noted the normal respiratory fremitus, the vocal fremitus, the 
normal cardiac impulse and thrill ; or the abnormal fremitus which 
is produced by consolidation of pulmonary tissue, its absence in 
effusions, and the thrill of aneurisms. 

By vocal fremitus we mean the voice vibration. This is esti- 
mated by placing the hand upon different portions of the chest ; but 
it must be borne in mind that there are many conditions consistent 
with health that give rise to difference in vibrations in different 
individuals, thus the amount of muscle or fat over the surface, 
the character of the voice itself; and it must also be borne in 
mind that it is somewhat more marked on the right side than on 
the left, owing to the fact that the right side is usually more 
fully developed, and that the heart occupies a large space on the 
left. 

In testing the vocal fremitus, the applicant should be made to 
repeat slowly and distinctly certain sounds, and careful attention 
should be paid to them, thus the numbers " twenty-three," " twenty- 
four," or " ninety-eight," " ninety-nine," preferably the latter, are 
those used. 

Increased vocal fremitus, when found associated with other 
physical signs of consolidated tissue, is a very important factor in 
life insurance examinations. 

Diminished vocal fremitus, when found associated with other 
signs of fluid or cavities filled with air, is important confirmatory 
evidence. 



EXAMINATION OF THE LUNGS. 37 

Pleural fremitus is the grating which is transmitted to the hand 
from roughened pleura ; this should always be sought for. 

Bronchial fremitus shows the presence of mucus in the bronchial 
tubes, and is also important when associated with rales heard upon 
auscultation. 

PERCUSSION. 

It is not necessary in a book of this kind to consider the subject 
of percussion in the same light as we would if writing a book 
on physical diagnosis. A physician who accepts the position 
of Examiner for an insurance company is supposed to be suffi- 
ciently educated to know what percussion is, and what is its object; 
but, by all means, he should have availed himself of opportunities 
to have studied percussion on the normal individual, as it is the 
recognition of normal sounds that is necessary for him now. In 
my experience in teaching physical diagnosis, not sufficient stress 
has been laid upon this, and students are taught the deviations that 
exist without ever having their ears tuned to the natural sounds and 
the normal differences. To say that a percussion note is normal 
and another is not is often an extremely difficult matter ; so much 
depends on the individual, the depth of the chest, the amount of 
air in the lungs, the character of the breathing, etc. What we 
wish to determine by percussion is to note from the character of 
the sounds exactly the condition of the tissue beneath. When we 
percuss over that portion of the chest in which there should be 
nothing but lungr tissue filled with air, we want to be able to note 
the differences that would arise should this air be contained in a 
cavity or in numerous air cells, or should solidification of tissue be 
found there. Upon percussing a solid organ, as the liver, we get 
an entirely different note, and the ear should be accustomed to 
the differences between the percussion note of a solid body, of a 
cavity containing fluid, air in numerous cells, air in one cavity 
communicating with others, or air contained in a cavity having 
one communication, as the stomach. 

The applicant should stand erect, hands by the sides, and both 
sides of the chest, as nearly as possible, placed under the same con- 
ditions. The Examiner, standing in front, should place the first two 
fingers of the left hand upon the chest on one side and gently tap 
with the fleshy part of the two fingers of the right hand. There 
should be freedom in the use of the fingers. The Examiner should 
percuss from the wrist, or if a deep stroke is necessary he should 



38 HOW TO EXAMINE FOR LIFE INSURANCE. 

make slight use of the forearm ; he should strike with the point of 
the fingers, as perpendicularly as possible, and the percussing finger 
should be allowed to gently- rebound from the finger struck. It is 
not necessary that any force should be used in percussing, as the 
slightest tapping which will convey the sound to the practiced ear 
will be sufficient, unless it is intended to bring out the sounds of 
tissue far away from the chest wall, when more forcible percussion 
will be necessary. 

The old saying, "that dirt is nothing but misplaced matter," is 
exemplified in percussion notes, as percussion sounds are only ab- 
normal when they are found where they should not exist ; thus, a 
dull percussion note would be abnormal at the apex of the lung 
but normal over the body of the heart, a tympanitic note would 
be abnormal over the lung but normal over the stomach. In this 
way great care should be taken by the Examiner that he recognizes 
what sort of tissue should exist beneath his finger before he elicits 
the percussion note. 

Let us, for a moment describe what should be found upon per- 
cussing the normal chest. It will be observed that apart altogether 
from the precordial region the percussion note is not the same at 
all parts. Let the clavicle itself be percussed, and it will be found 
that the outer half is duller than the inner, while, again, it becomes 
less resonant at the sternal articulation. Over the infra-clavicular 
region there is less resonance and more resistance toward the 
sternum, till we find we are catching the dullness of the great ves- 
sels of the mediastinum. Such details, however, should not be 
committed to memory from books ; they are to be sought out by 
each one for himself, bearing in mind that differences, occurring 
even over the same parts in different healthy individuals, demand 
not an absolute but a comparative standard. 

But the general features of the different regions should have 
some attention from the first. The right mammary region, with 
its commencing liver dullness, and the right infra-mammary, where 
that dullness is more marked ; the cardiac dullness of the left mam- 
mary region, and the stomach tympanitic note of the left infra- 
mammary, should all be examined. The Examiner should be 
prepared to find the percussion of the upper part of the posterior 
surface of the chest comparatively unsatisfactory, at least over the 
scapulae. It is difficult or impossible to make out finer distinctions 
over them, where the percussion stroke itself requires to be so much 



EXAMINATION OF THE LUNGS. 39 

stronger to penetrate the greatly-thickened parietes at that part, 
though it is most important to percuss carefully the supra-scapular 
region. 

Deviations from the normal sound would constitute disease, and 
of course these deviations maybe of various kinds, dependent upon 
the condition of the portion affected ; thus we may have, first, 
absolute dullness, the result of fluid, tumors or aneurisms ; second, 
slight dullness, from incipient phthisis, plastic pleurisy or enlarged 
glands ; third, increased resonance, from emaciation of the chest 
wall, emphysema, pneumothorax, or by contrast with the other 
side; fourth, tympanitic note, heard over a small cavity surrounded 
by solidification, or from the solidification overlying enlarged 
bronchial tubes ; fifth, cracked-pot sound, which indicates a cavity 
near the surface ; sixth, amphoric resonance, which is produced by 
a large cavity near the surface; seventh, the sense of resistance, the 
feeling of solidity upon percussing, which the experienced Examiner 
will note apart from the percussion sounds. 

Auscultation. — The applicant should be in the same position as is 
required for percussion. If immediate auscultation is used and the 
auscultator's ear is directly applied to the chest, there should be 
little, if any intervening substance that would give rise to sounds 
that might confuse him. The Examiner may either apply his ear 
directly to the chest or use a stethoscope. My advice certainly 
would be that he would accustom himself to the sounds by both 
methods. At times he will need the stethoscope in a particular 
area where he suspects local disease, but if he accustom himself to 
the use of the stethoscope altogether, and, for some reason or 
another, forgets to take it with him, he will find himself in a rather 
embarrassing predicament. 

Placing the ear upon the chest wall, it is necessary for the Exam- 
iner to take into consideration various conditions — first of all, the 
character of the respiration, whether it is soft or noisy ; secondly, 
the differences between inspiration and expiration ; thirdly, the 
presence of abnormal sounds during these acts. The applicant 
should be asked to breathe through his mouth and thereby the 
sounds made in the nose will not be transmitted to the lung. The 
respiratory sound will vary in different portions of the chest ; in 
certain parts, especially the apices, it will be soft, the respiration 
freer, and inspiration and expiration scarcely audible; abnormal 
changes would be blowing inspiration and prolonged expiration; 



40 HOW TO EXAMINE FOR LIFE INSURANCE. 

over the bronchial tubes it assumes more of a bronchial character, 
expiration is more prolonged and often exceeding that of the in- 
spiratory sound. There is a slight difference between the right 
and left infra-clavicular regions, the right being more prolonged 
in expiration and somewhat higher pitch than the left. 

Normal sounds become abnormal when heard elsewhere than 
where they belong. The bronchial breathing, which is heard over 
the larynx or trachea, is normal, but becomes abnormal when heard 
in any other portion of the chest. 

Of course the character of the breathing depends greatly upon 
the amount of air which enters the chest. Some individuals who 
have feeble chest development, and who live sedentary lives, not 
given to athletic exercise, have much feebler respiratory sounds 
than those who have developed their lungs, and yet at the same 
time they may not be affected with disease. 

In using the stethoscope the following precautions should be 
taken : The Examiner should not press heavily with the stetho- 
scope, and he should always be careful to adapt the bell of the 
stethoscope to the chest ; he should place his ear to the ear-piece 
without moving the stethoscope in the least from its position ; for 
there is not a sound but what would be thereby modified; should 
it accidentally occur, the vibration of the air itself in the stetho- 
scope ought to be at once recognized by the practiced ear, warning 
him that some inequality of the chest surface, we shall suppose, is 
displacing the bell of the stethoscope. 

The auscultator should never put himself into an awkward posi- 
tion by bending too far over the applicant, for he might in this 
way fail to hear an otherwise audible sound. Obviously, too, 
nothing should touch the stethoscope or rub against the applicant's 
chest, or otherwise the most startling friction sounds may be heard. 
Hair on the chest, a starched shirt bosom, or even a silk undershirt 
may produce fine crackling sounds from contact with the stetho- 
scope. The simplest and most effectual plan to obviate the first of 
these is to lay on the skin a small piece of wet blotting paper, suffi- 
ciently large for the bell of the stethoscope. 

The respiratory murmur varies considerably within the normal 
limits ; emaciation of the chest wall will intensify the sound ; un- 
equal muscular development will also affect it. 

In disease, we notice alterations in the respiratory murmur — 1st, 
in degree. It may be diminished by anything that will diminish 



EXAMINATION OF THE LUNGS. 41 



the amount of air entering the lungs. We find this to be the case 
in asthma and bronchitis, the pressure of or the mere presence of 
aneurisms or other tumors, also in emphysema, in collapse of the 
lung, or when there is any solidification. 2d. The respiratory 
murmur may be entirely suppressed by interference with the entrance 
of the air, or by something which affects the transmission of the 
sound to the ear, such as effusion. 3d. The respiratory murmur 
maybe increased, owing to a larger amount of air going into the air 
vesicles from over-exertion of the lung, due to obstruction in other 
parts ; in other words, what is known as supplementary respiration. 
4th. The respiration may bt jerky, which is an abnormality in char- 
acter ; this is by some supposed to be indicative of incipient phthisis 
when heard at the apex, and considered one of the first evidences of 
this disease, though by others less stress is laid upon it, as they con- 
sider it to be of nervous origin. 5th. The expiratory sound may be 
prolonged ; this is an evidence of early tubercular infiltration, and is 
also found in emphysema. 6th. The respiration may be harsh; this 
is found in tubercular infiltration. 7th. The respiration may be 
bronchial ; this refers to expiration as well as inspiration. Of course, 
when found over the large bronchial tubes, this would be normal, 
but when heard elsewhere, it is an evidence of disease ; it is found 
particularly in consolidation. 8th. Respiration may be cavernous, 
that is, hollow; this is produced by a cavity of considerable size 
near the lung surface, or with surrounding condensation, containing 
little or no fluid, and communicating with one or more bronchi ; 
or it may be produced by an enlarged bronchus. 9th. Respira- 
tion may be amphoric, which is a very hollow sound, and can 
be produced by a large cavity containing air, or in pneumothorax. 
It is like the sound produced by blowing over the mouth of a 
jar. 

Rales. — When the bronchial tubes contain material which is ab- 
normal to them, the air passing through them produces certain 
sounds which are called rales; these may or may not be important, 
but should always be noted. These may be dry or moist ; when 
dry they are called sibilant or sonoroics, and are then associated with 
bronchitis, bronchial catarrh, or asthma, and may be caused by 
swollen mucous membrane, the presence of mucus or pus, or a spas- 
modically constricted bronchus, or a foreign body in the bronchial 
tubes. The moist rales may be considered to be of three kinds — 
crepitant, subcrepitant, and coarse or gurgling rales. 



42 HOW TO EXAMINE FOR LIFE INSURANCE. 

Crepitant rales are heard only in inspiration, and sound like the 
rustling of silk ; it is typical of the first stage of lobar-pneumonia, 
and when heard at the apex it is a strong point in favor of the early 
stages of pulmonary phthisis. 

The sub-crepitant rales are the same as the crepitant, only they 
are heard in expiration as well as inspiration; they are found in 
bronchitis, and also in the earlier stages of pneumonia, and when 
heard at the apex are also a serious matter ; if heard at the base, 
they are an evidence of dry pleurisy, and when heard throughout 
both lungs they denote bronchitis. The clicking rale which is often 
heard at the apex is a common sign of the bronchial catarrh 
attending tubercle, in fact, all fine moist rales about the apex should 
be carefully ?ioted. 

Gurgling rales are heard only over cavities or large bronchial 
tubes. 

It is safe to say that when rales are heard, the applicant is not a 
fit subject for Life Insurance; but if he is robust in appearance and 
has no other evidence whatever of pulmonary trouble, they may 
simply denote bronchitis, and the case should be postponed for a 
few days and then reexamined; but if there is any tendency to 
phthisis in the family of the applicant, and he is anaemic and has 
any evidences of phthisical diathesis, the case should certainly not 
be recommended to the Home Office. 

The word rale has also been applied to a pleural friction sound. 
In health, the pleurae should move silently upon each other, with a 
free movement, but the slightest roughening of either surface will 
give on inspiration or expiration, or both, a sound in proportion to 
the amount of pleural tissue affected. This sound comes very much 
sooner to the ear than the ordinary intra-vesicular rale, and the 
very fact that it is superficial, limited in area, possibly influenced by 
pressure, but not by coughing, are sufficient evidences of their 
situation ; of course, the presence of this sound would require the 
postponement of the applicant. 

Vocal Resonance. — Vocal resonance is an important feature in the 
detection of pulmonary disease. By it we mean the transmission 
of the voice and its appreciation by the ear. It is influenced by sex, 
being louder in the male ; the more capacious the chest, the thinner 
the chest wall, and the deeper the tone of voice, the louder the vocal 
resonance. Vocal resonance should be tested by making the appli- 
cant pronounce the words " one," " two," " three," or " ninety- 



INCIPIENT PHTHISIS. 43 

eight," " ninety-nine," slowly and distinctly, while the ear of the 
Examiner is upon the chest. 

The vocal resonance may be increased by consolidation of the 
lung of any sort, without occlusion of the larger bronchial tubes. 

The vocal resonance may be diminished by fluid in the chest 
wall, by occlusion of the main bronchus from tumors or aneurisms, 
by obstruction of the bronchial tubes by means of secretion, or by 
pneumothorax. 

The vocal resonance may be altered in quality by anything that 
will change the character of the transmitting medium ; thus, a thin 
layer of pleuritic effusion will produce a sound known as aegophony. 



CHAPTER X. 

INCIPIENT PHTHISIS. 



In thus rapidly passing over the examination of the lungs, we 
have endeavored, as far as possible, to avoid anything doubtful, and 
have insisted upon the Examiner placing upon the examination 
blank clearly the conditions that his methods have enabled him to 
observe, and by taking his examination in its entirety, the Home 
Office can be the judge of the value of the points from it; and if 
further investigation is needed, the lines of this investigation can 
be indicated by special correspondence. 

It is well here to dwell for a moment upon the importance of the 
detection of the very earliest symptoms of pulmonary disease. It 
must be borne in mind that an individual is very much more dis- 
posed to insure, who believes that he is not up to the standard. It 
has been said that if we could get the conscientious opinion of an 
individual as regards his own state of feeling, we would often arrive 
at far greater perfection in the selection of risks. The man who 
knows that he is not up to par, feels the necessity of insurance, but 
the phthisical man, and a strange freak it is in this disease, imag- 
ines himself improving in health until the day of his death. He 
will not acknowledge that there is anything the matter with his 
lungs, and with perfect good faith he will conceal the occasional 



44 HOW TO EXAMINE FOR LIFE INSURANCE. 

slight haemorrhages which are so pathognomonic ; he will conceal 
the hectic, and not mention the emaciation and slight morning 
cough or expectoration and the shortness of breath, and in doing 
so, he by no means does it with the intention to defraud the Com- 
pany, but simply because it is a part of his disease to imagine his 
symptoms to be trivial, and his condition to be that of good health. 

An Examiner should always be on his guard for this very thing, 
as it is an extremely difficult matter, and one of very great import- 
ance, for the evidence of incipient phthisis to be noted in its very 
earliest stages. 

Dr. Harris* calls especial attention to the importance Oi haemop- 
tysis amongst the earliest symptoms, especially the repeated slight 
haemorrhages ; he lays stress, also, upon the family history, not- 
withstanding the attention paid at the present day to the subject of 
the tubercular bacillus ; for clinical evidences that phthisis is trans- 
mitted is undoubted. Among the earliest positive physical signs 
may be noted the impaired movement of one or both apices. These 
may be noted by the Examiner standing behind the applicant, 
placing his hands upon the subclavicular region of each side and 
noticing whether both sides rise equally and readily during inspira- 
tion. 

Dr. Harris also gives another sign which deserves attention ; this 
is the lower limit of pulmonary resonance in the supra-clavicular 
and supra-scapular regions, on the affected as compared with the 
sound side. This may be detected in cases where no dullness is 
present. Any dullness, or tonelessness on percussion at one apex 
must in a doubtful case be regarded as of great significance. The 
auscultatory signs are frequently absent, but this can be explained 
by the fact that in such cases the process is deep-seated in the 
lung, and that the sounds produced by the consolidation are masked 
by the normal vesicular murmur. 

In the early stage the vesicular murmur may be feeble, it may 
be somewhat harsh or bronchial in quality, or the expiration may 
be prolonged, but it should be noted that this difference should 
exist on one side only or to a more marked degree. 

The rales which are usually present in early phthisis may vary 
from day to day owing to the changes in degree of the bronchial 
catarrh present in the neighborhood of the tubercular deposit. 

* London Lancet, December 21st, 1889. 



INCIPIENT PHTHISIS. 45 

The presence of dry crepitations, which usually disappear on 
taking deep breath, and are accentuated by coughing, and fre- 
quently hoard alone in the supra-clavicular and supra-scapular 
regions, are of great value in early phthisis. 

Then again in other cases pleuritic friction may be an early sign, 
especially if apical. 

The clinical thermometer should be used by the Examiner in all 
doubtful cases. It is especially important in the detection of 
incipient phthisis, and if the applicant exhibits any of the symp- 
toms just enumerated, the Examiner would fail in his duty did he 
not apply this test. But he should proceed still further, and make 
a microscopical examination of the sputum for the tubercular 

Fig. 6. 




Tubercle-bacilli in sputum (Shakespeare). X 600. 

bacillus (see Fig. 6) and for the elastic fibres of lung tissue. Dr. 
J. P. Crozer Griffith suggests the following methods as the most 
readily adapted for this purpose : — 

The applicant should be asked to preserve some of the sputum 
as clean from food or other matters as possible. When there is 
but little expectoration it is well to have some of that raised in the 
morning saved, as there is often more at that time. This should 
be placed in a bottle and given to the Examiner. It is as well to 
impress the applicant with the fact that but a very small quantity 
is necessary. The sputum should now be poured out on a piece 
of glass — window-glass will do — preferably over a black surface. 
A very minute portion of the greenish part — if there is any such — 
is now picked out with a clean, mounted needle, and pressed between 



46 HOW TO EXAMINE FOR LIFE INSURANCE. 

two cover-glasses. These are now slid apart — not lifted up. They 
are then passed quickly through the flame of a Bunsen burner or 
alcohol lamp, with the sputum side up. Do this two or three 
times, till the sputum is dry. Be careful not to burn. Now they 
are ready for staining. The Ehrlich's Gentian-violet-anilin-water 
may be used, as it is sure, if it is slow. 

Into a test-tube, half full of water, pour a few drops of anilin. 
With the thumb over the end, now shake this well for some min- 
utes, then filter. This makes the anilin water ; the water having 
taken up a certain amount of the anilin. A bottle may be kept 
of saturated alcoholic solution of Gentian violet. To the anilin 
water in the tube add a few drops of the violet solution, until the 
water is just becoming opaque. Very few drops will do this, and 
it is easy to tell when there is enough. Filter some of this into 
a watch-glass and in it place the prepared cover-glasses, float them 
on it face down, if possible, though it does not make much differ- 
ence. Let them remain here, covered up, for twenty-four hours. 
To continue the process, take the cover-glasses from the dye, dip 
them for a second or so in a solution of three parts nitric acid in 
one-hundred parts alcohol. Indeed, it is often well to dilute this 
still more, in order to make it more manageable. They are now 
washed quickly in two or three washings of alcohol until the blue 
color has just about disappeared. They are now dried without 
heat and examined in oil of cloves. It is, however, difficult to 
work without a background to the bacilli, so it is usual to make a 
double stain, as follows : Put a little powdered vesuvin, or Bismarck 
brown, into a test-tube with water, shake and filter; the color should 
not be too deep. Having removed the cover-glass from the alcohol 
dip it in water, and then immerse it in the brown dye for seconds 
or minutes, depending on the strength of the dye. It is only 
necessary to get a very faint brown stain, just enough to stain the 
cells of the sputum so as to focus easily in looking for the blue 
bacilli, if they are but few in number. The cover-glass is now 
washed in water and dried without heat, as before, and examined 
in oil of cloves, or balsam. The solution should always be made 
fresh. It is not much trouble. 

Another much shorter method is that of Ziel, with carbol-fuchsin 
and heat. The solution is prepared by adding IO c. c. of a satu- 
rated solution of fuchsin to 90 c. c. of a five per cent, aqueous 
solution of carbolic acid. This will keep ; filter each time. The 



EXAMINATION OF THE ABDOMEN, LIVER AND BOWELS. 47 

method is the same as that just described, except that by warming 
the watch-glass in which the dye is, until bubbles of steam rise, 
the whole staining can be accomplished in a few minutes. It is 
not as eood as Ehrlich's method. For a double stain use an 
aqueous solution of methyl blue, and examine in turpentine instead 
of oil of cloves. 

As regards the elastic fibres, the proper way is to spread a con- 
siderable quantity of sputum in a thin layer on the glass over a 
black surface. Now pick out some of the little whitish points and 
examine them, they may be elastic fibres. Probably a still surer 
way is to boil the sputum in a ten per cent, solution of caustic 
potash. Let stand in a conical glass for twenty-four hours and 
examine the sediment. 



CHAPTER XI. 

EXAMINATION OF THE ABDOMEN, LIVER AND BOWELS. 

In the examination of the abdomen, we make use of the follow- 
ing methods — inspection, palpation, percussion and auscultation. 

It is not intended that, in the examination of the abdominal 
viscera, the applicant should always be stripped, as such examina- 
tion would not be called for; sufficient evidences of disease would 
exist by which the Examiner could make positive statements upon 
his paper that would cause the rejection of the applicant by an 
examination made over the under-shirt, and, in a majority of cases, 
it will not be found necessary to remove the ordinary linen shirt 
which every one wears ; it can be rolled up so as to be out of the 
way. 

Inspection. — Here, as in the examination of the heart and lungs, 
we note the form and movement of the abdomen. 

Palpation. — This, in the examination of the abdomen, occupies 
the important place, just as auscultation does in the examination of 
the heart and lungs. Careful palpation of the abdomen should be 
made, in order to bring out any irregularities which should denote 
tumors, enlargement of the liver or spleen, such as cancer, disease 



48 HOW TO EXAMINE FOR LIFE INSURANCE. 

of the mesenteric glands, etc. The right iliac fossa should be care- 
fully examined for evidences of typhlitis or perityphlitis, and the 
applicant should be carefully questioned in regard to symptoms of 
gastric cancer, such as pain, recent rapid loss of flesh, hemorrhages 
from the stomach, vomiting immediately before, at or after meals. 
The presence of fluid in the abdominal cavity should always be 
looked for, and if the applicant be a female, all enlargements or 
tenderness in the ovarian region should be particularly studied. 

Percussion. — As stated in a former chapter, the normal percussion 
note of the abdomen is tympanitic. By percussion we are enabled 
to recognize the presence of fluid or tumors in the peritoneal cavity. 

If any suspicious symptom should appear in the abdominal ex- 
amination, the applicant should be required to lie on a lounge and 
a more careful examination made by means of deep pressure or more 
forcible percussion, and then the clothing of the part should be 
removed. 

Auscultation. — In the examination of the abdomen, auscultation 
is a minor feature, but the Examiner should be familiar with the 
sounds, in order not to be misled when they are conducted, as is 
frequently the case, some distance into the thorax. It is valuable 
in suspected pregnancy or aneurism. 

THE LIVER. 

The liver is carefully examined while the applicant is standing, 
for any evidence of tenderness or bulging. Its situation is marked 
by percussion. It is scarcely necessary to state the liver outlines ; 
it does not reach below the territory of the ribs and extends upward 
about the breadth of two fingers (see Plate 3). On the opposite side 
the spleen can also be outlined. 

THE BOWELS. 

It is well, especially if, in the course of conversation with the appli- 
cant, any suspicion should arise in the mind of the Examiner as to 
disease of the rectum, that certain pointed questions should be 
asked in regard to haemorrhoids, cancer of the rectum, etc., and 
if the Examiner deem it necessary, he should insist upon making 
a personal examination of the rectum, for if haemorrhoids, fistula or 
cancer of the rectum exist, the applicant is not a fit subject for life 
insurance. ' 

This is a very important matter, as, of course, these parts are 



EXAMINATION OF THE KIDNEYS. 49 

concealed, and the Examiner is not called upon to make a thorough 
rectal examination, nor indeed, to examine the private parts of an 
individual unless his suspicion has been aroused. There have been 
cases of concealed rectal cancer, cancer of the testicles, etc., that 
have escaped most cautious Examiners, and it is on this account 
that attention is especially called to this subject. 

If the applicant gives a history of rupture the Examiner should 
see for himself that a suitable truss is worn; every case of " cured 
rupture" should be carefully examined. 



CHAPTER XII. 

EXAMINATION OF THE KIDNEYS. 

One of the most difficult subjects of all in connection with an 
examination for life insurance is the detection of the earliest evidence 
of disease of the kidneys. The normal amount of urine passed in 
twenty-four hours by an adult male is about forty-five ounces, and 
he usually urinates about four times a day. The fluctuations in 
amount and frequency are dependent upon weather, exercise and 
food. If the applicant is examined at the Company's Office or the 
office of the Medical Examiner, a pitcher or cup should be handed 
him, and he should be requested to pass a sample of his water for 
examination ; if this is impossible, the Examiner should give the 
applicant a wide-mouthed vessel and ask him to step into the near- 
est closet and pass some of his water into the vessel. The reason 
that it is important, in cases where large amounts of insurance are 
demanded, that the urine should be passed in the presence of the 
Examiner is, that cases have been known wherein applicants have 
carried with them urine which they have substituted for their own, 
the former being healthy and the latter diseased ; of course, this 
is impossible if the urine is warm when handed to the Examiner. 

Although the Medical Examiner should always be on his guard 
to prevent substitution of urine, and, indeed, to prevent all attempts 
at fraud, it is a great mistake for him to treat applicants as if their 
intention was always to defraud the Company. Fraudulent cases 

4 



50 HOW TO EXAMINE FOR LIFE INSURANCE. 

are constantly met with in a life insurance examination, but they 
are exceptions to the general rule, and no Examiner should allow 
any word or act of his to throw any suspicion on the applicant who 
is before him ; his manner should always be courteous, he should 
be reserved in his opinions, and he should retain his views for his 
Medical Chief at the Home Office of the Company, and should 
any doubts arise in his own mind, he should, by tact and watchful- 
ness, guard against any perpetration of fraud. I emphasize this 
fact, because complaints are frequently made that Examiners are 
not sufficiently courteous to an applicant ; that they frequently 
offend many, who are perfectly honest in their desire to obtain 
insurance, by making evident suspicions which arise in their own 
minds, but which have no foundation in fact ; that they are frequently 
too fussy, too talkative, and in this way hinder the business of the 
Company instead of increasing it. A hint in this direction may 
frequently be of service to those who do not understand what is 
wanted of them, and, indeed, this book is not intended to instruct 
the experienced Examiner, who has learned by years of service and 
constant contact with individuals exactly what the duties of his 
position are, but it is intended simply to instruct and to put on his 
guard the recent appointee, who is willing to learn if he only knows 
where to obtain the information. 

If it is impossible for the applicant to give a sample of his urine 
at the time of the examination, the proper thing to do is to hand 
him a clean bottle, with the Examiner's address, and ask him to fill 
it with his own urine, and to send it, together with a note, to the 
Examiner, stating that the urine contained in the bottle is that 
which he voided, and the Examiner should send this note with his 
report to the Home Office of the Company. 

SPECIFIC GRAVITY. 

The specific gravity of urine in health varies between 1015 and 
1025. It shows the ratio between the water and solids in the urine. 
It may be increased by less water or more solids, and may be 
diminished by more water or less solids, all within the bounds of 
health. 

The specific gravity should first be taken ; this is important for 
several reasons, one is to prevent the substitution of pure water for 
urine ; secondly, because usually urine containing sugar is of greater 
specific gravity (1025 or more), though exceptions to this exist; 



EXAMINATION OF THE KIDNEYS. 5 I 

thirdly, because low specific gravity with a large quantity of urine 
passed, is diagnostic of diabetes insipidus, and also because low 
specific gravity (ioio or less) with or without a slight trace of 
albumin is found in the earlier or later stages of some forms of 
Bright's disease; this latter is a most important matter and not to 
be overlooked. 

The urine should now be allowed to cool, and then a careful 
series of tests made. 

ALBUMIN. 

It is most important that the urine should be examined for the 
slightest trace of albumin. It may be present in one sample and 
absent in others. It may not record itself until the test-tube has 
been set aside for a while. This form of albuminuria may be the 
earliest indication of kidney disease. 

The examination for albumin should be made in the following 
manner : It simply requires a perfectly clean test-tube, a spirit lamp, 
and some pure nitric acid and a background of black, which will more 
readily show a trace of albumin should it appear. A small quan- 
tity of urine should be placed in the test-tube, and should be boiled 
thoroughly, preferably the upper portion boiled first, and if a cloud 
shows itself, it is either caused by phosphates or albumin, and in a 
majority of the cases it will be found to be phosphates. A drop of 
nitric acid allowed gradually to trickle down the test-tube when it 
reaches the urine will soon dissolve the phosphates and leave the 
urine perfectly clear; but should this clearing not take place, it is 
probable that the cloud is due to albumin ; and to prove this, some 
cold urine should be placed in a test-tube, and by means of a 
pipette, a small quantity of nitric acid should be allowed to 
gradually flow down the sides of the tube ; being heavier, it will 
sink to the bottom, and by holding the test-tube against a black 
background, the point of contact between the acid and the urine 
should be carefully examined, and if a cloudy or opalescent ring 
is noticed, it is probably due to albumin. If it fails to appear, set 
the test-tube aside and examine again in the course of an hour; 
this can only be useful if the test be boiled alone, as nitric acid 
would dissolve the albumin. 

Where leucorrhcea is suspected, or has existed, in a female appli- 
cant, the cloud may be mucus, or the mucine contained in the dis- 
charge ; in such cases it is well, before pronouncing definitely, to 
filter the urine, and then test it. The best filter is probably a small 



52 HOW TO EXAMINE FOR LIFE INSURANCE. 

quantity of cotton, chemically clean, in a glass funnel. The albu- 
min of pus will not filter out. 

If the amount of albumin be very small indeed, merely a trace, 
the applicant should be required to furnish another sample of 
his urine — no explanation should be given that might awaken his 
suspicion — and a microscopical examination of this should be 
made; but a report of the first finding should always be made 
to the Home Office. 

There is a form of albuminuria which is occasionally met with, 
called the " albuminuria of adolescence," as it usually occurs at 
that time and is more common in boys. The amount of albumin 
varies; it is increased after meals; is absent frequently in the 
morning; follows exercise and fatigue. No casts are ever found in 
such urine. It is supposed that no structural change in the kidney 
and consequent obstruction to the circulation has occurred, but it 
is possibly due to some defect in the composition of the albumin 
in the blood, the result of mal-assimilation, or to a neurosis. 

T. Grainger Stewart tells us that there is no sufficient proof that 
albumin is normally discharged from the human kidneys, there- 
fore, we cannot but believe that the presence of albuminuria is, to 
a more or less extent, pathological, and even when not associated 
with any other evidences of disease of the kidneys, it renders the 
applicant, for the time being, uninsurable, as would bronchial 
catarrh, anaemia, and so forth. The retinal symptoms which are 
associated with chronic Bright's disease, though usually appearing 
late, should be sought for in all cases where a suspicion of Bright's 
disease exists, and an Examiner should add an ophthalmoscopic 
examination to his other methods of investigation in doubtful 
cases. 

SUGAR. 

For the detection of sugar, care is necessary. 

A slight amount of sugar found after meals has by no means the 
same significance that attends the trace of albumin. 

A slight trace of sugar, which is not constant, is not always the 
sign of diabetes mellitus, and may be an evidence of transient func- 
tional disorder, especially in young persons ; nevertheless it should 
give rise to suspicion and be most carefully investigated. 

First of all, it is absolutely essential to have chemicals that are 
of undoubted value. Fehling's test solution is undoubtedly the 
best, when new and carefully prepared, and every Examiner for 



EXAMINATION OF THE KIDNEYS. 53 

Life Insurance should have on hand a supply which is perfectly 
clear and has not undergone decomposition, or, at least, he should 
have on hand the materials so that he can make it up for himself. 
The large drug houses supply it on demand, and a majority of the 
drug stores at the present day are capable of making up solutions 
as often as the practitioner desires to have them made; those 
physicians living in country districts who propose to act as Insur- 
ance Examiners should prepare themselves for this examination by 
having the formula of Fehling's solution,* so that they can prepare 
it when needed. 

Pour a small quantity of the solution in a test-tube, dilute it with 
four times the quantity of water, and boil it. Should it not discolor, 
and no precipitate take place, the solution will be satisfactory. An 
equal quantity of urine is now poured slowly down the side of the 
tube, and the two are boiled together for a short time. The presence 
of sugar will show a decided reaction, and the mass turning orange 
red will convince one that sugar is present ; of course, when a 
large amount of sugar is found, after it has cooled and settled, the 
red suboxide of copper will be found deposited in the bottom of the 
tube. A high specific gravity is in favor of the presence of sugar. 

If there be no pure, fresh Fehling's solution, it is well to make 
use of Trommer's test, which consists of equal parts of urine, liquor 
potassa, and a solution of sulphate of copper, 10 grains to the 
ounce. These are mixed in a test-tube and shaken until they 
are clear. They are then boiled, and if the solution becomes 
opaque and an orange-red precipitate is formed, sugar is undoubt- 
edly present. 

When no sulphur is present in urine, and therefore the urine is 
free from albumin, the bismuth test for sugar is an excellent one. 
Add to urine in test-tube an equal volume of liquor potassse or 
sodae and a small pinch of ordinary subnitrate of bismuth ; then 
boil. If sugar is present black metallic bismuth will be deposited. 

In transmitting the report to the Home Office, as to the results 

* Fehling's test is absolutely certain, and the standard solution is prepared as follows : 
Take 34.64 grammes (1 Troy ounce, 54 grains) of pure crystallized sulphate of copper 
previously powdered and pressed between blotters and dissolved in about 200 c. c. (6 fluid 
oz., 5 fluid dr.) of distilled water. Take 173 grammes (5 Troy oz., 4 dr., 30 grains) of 
tartrate of soda and potassa (Rochelle salts), and dissolve in 480 c. c. (16 fluid oz.) of a 
solution of pure caustic soda, sp. gr. 1.14. Mix the two solutions and dilute with distilled 
water to 1 litre (21 pints). 

This is apt to decompose after several months, and should be kept in a cool place in a 
gla^s-stoppered bottle. 



54 HOW TO EXAMINE FOR LIFE INSURANCE. 

of the tests for both sugar and albumin, it is always necessary to 
state whether or not the applicant exhibits any of the symptoms 
attendant upon diabetes or upon Bright's disease. 

A test also based on the precipitation of cuprous oxide when 
glucose is boiled with copper salts in the presence of alkalies has 
been arranged by Dr. W. S. Haines, of Chicago. It is convenient 
for country practitioners. 

The test is prepared in two solutions, bottled separately to insure keeping. 
Full directions are given with each test, and test-tubes with holder are packed 
with the bottles in each box. The test is thus ready for immediate use and 
takes but a moment for its manipulation.* 

Directions. — Mix in a test-tube equal parts of Parts I and II, filling the tube 
about one-third full. Heat to boiling, and add a little of the urine. A change at 
once or on further boiling, to an orange or reddish hue with turbidity, indicates 
diabetic sugar. This change should occur within a minute, as continued boil- 
ing may produce a precipitate with other matter present in the urine. If no 
turbidity appears, to show that the solutions are uninjured by age add to the 
hot mixture and urine a few drops of dissolved glucose or honey and boil. If 
the orange turbidity is now produced, it proves the virtue of the solutions and 
previous absence of glucose. 

Undoubtedly the fermentation test is the most certain of all, 
though not very delicate, and should be employed when sugar is 
suspected. This is made by means of the saccharometer. 

The saccharometer here presented is one of the simplest in use. 

DIRECTIONS. 

Take one gramme of commercial compressed yeast (or T X F of a cake of 
Fleischmann's Yeast), shake thoroughly in the graduated test-tube with 10 c.c. 
of the urine to be examined. Then pour the mixture into the bulb of the 
Saccharometer. By inclining the apparatus the mixture will easily flow into 
the cylinder, thereby forcing out the air. Owing to the atmospheric pressure 
the fluid does not flow back but remains there. 

The apparatus is to be left undisturbed for 20 to 24 hours, in a room of 
ordinary temperature. 

If the urine contains sugar, the alcoholic fermentation begins in about 20 to 
30 minutes. The evolved carbonic acid gas gathers at the top of the cylinder, 
forcing the fluid back into the bulb. 

On the following day the upper part of the cylinder is filled with carbonic 
acid gas. The changed level of the fluid in the cylinder shows that the reac- 
tion has taken place and indicates by the numbers — to which it corresponds — 
the approximate quantity of sugar present. 

* Prepared by Willis G. Gregory, M.D.,PH.G., Manufacturing Pharmacist, Buffalo, N. Y. 



FA A MI NATION OF THE KIDNEYS. 



55 



If the urine contains more than one per cent, of sugar, then it must be diluted 
with water before being tested. 

Diabetic urines of straw color and a specific gravity of 1018-1022 may be 
diluted twice ; of 1022-102S, five times ; 1028-1038, ten times. 

The original (not diluted) urine contains in proportion to the dilution two, 
five or ten times more sugar than the diluted urine. 

In carrying out the fermentation test, it is always recommendable to take 
besides the urine to be tested, a normal one, and to make the same fermentation 
test with it. 

The mixture of the normal urine with yeast will have on the following day 
only a small bubble on top of the cylinder. That proves at once the efficacy 
and purity of the yeast. 

Fig. 7. 




Max Einhorn, m.d. Eimer & Amend, New York. 

If there is likewise in the suspected urine a small bubble on the top of the 
cylinder, then no sugar is present, but if there is a much larger gas volume, 
then we are sure that the urine contains sugar. 



UREA. 

In rare cases it may be necessary to estimate the amount of urea, 
and for that purpose Dr. Chas. Doremus' apparatus is the simplest. 

The apparatus shown in the cut is designed for the rapid approximate 
estimation of urea. It yields, when the test is carefully made, results closely in 
accord with the theoretical. 

That determination of the quantity of urea voided is of importance in diag- 



56 



HOW TO EXAMINE FOR LIFE INSURANCE. 



nosis has long been felt, but the difficulties met with in the manipulation of the 
tests which were to supply the data were too irksome to physicians. 

REAGENTS NECESSARY. 

The Sodium Hydrate solution (ioo grammes to 250 c.c. of water, or 6 ozs. 
to 1 pint of water) will keep indefinitely when tightly stoppered. 

The Bromine may be removed from the bottle in which it is kept by means 
of the nipple pipette. 

Fig. 



= S 

- s 

— y» 

— u. 01 



— 9:02 
- *r 



I 003 



t-> 




Eimer & Amend, New York. 

i c.c. suffices for a test. More can be removed if a quantity of hypobromite 
is to be made up. Some care must be exercised in handling the Bromine, 
since it gives off irritating fumes — but by the above method of procedure no 
inconveniences ought to be experienced. 

The concentrated hypobromite must be diluted with its own volume of water. 
This can be done approximately. 

The long arm and the bend of the ureometer must be filled with the hypo- 
bromite. 

Having washed the pipette draw up exactly 1 c.c. of urine, pass the pipette 
through the bulb of the ureometer as far as it will go in the bend. Compress 
the nipple gently and steadily. The urine will rise through the hypobromite 
and the urea instantly decompose, giving off nitrogen gas. 

Withdraw the pipette after the urine has been expelled, taking care not to 



EXAMINATION OF THE KIDNEYS. 



57 



press the nipple hard enough to drive the air out after the urine, and read the 
volume of gas after allowing the froth to subside. The ureometer indicates, 
according to its graduation, either in milligrammes of urea i?i i c.c, of tcrine or 
grains of urea per fluid ounce of urine. 

It also indicates by the signs + and — on either side of the central division 
whether the urea is present in a normal quantity or is increased or diminished. 

In this connection it is well to remember that no two specimens from the 
same individual are alike when collected at different times of the day. Unless 
the urine of 24 hours is collected, mixed and a specimen taken, no accurate data 
can be had. Next to collecting the 24 hours urine and ascertaining the quan- 
tity voided, the morning urine, that passed on rising, is the best upon which to 
base a diagnosis. 

When the total quantity voided in 24 hours is known the calculation of the 
amount of urea is very simple. Multiply the result found in milligrammes by 
the number of cubic centimetres voided, or the grain per fluid ounce by the 
number of ounces voided. 

The percentage by volume, or milligrammes of urea per 100 cubic centi- 
metres of urine, is ascertained by multiplying the milligrammes of urea found 
by the test by 100. 

For country practitioners it is absolutely necessary to have some 
convenient method of making these urinary tests. There is sold 
an excellent pocket-case, which has the advantage of a small alcohol 
lamp attached to the top of the case (see Fig. 9).* 

The tests employed are as follows : — 



Fig. 9. 



ALBUMIN TEST POWDER. 

Keep in the office two bottles, the one containing pulver- 
ized citric acid, and the other pulverized potassium ferro- 
cyanide (yellow prussiate of potash). The pocket reage?its 
bottle is to be filled at intervals of about two weeks with 
approximately equal quantities of these powders and thor- 
oughly mixed by shaki?ig. They must be kept perfectly dry. 

To use, take about a drachm of the suspected urine and 
transfer to the test-tube with the aid of the pipette. Then 
drop into this about two or three grains of either of the 
powders above mentioned. If albumin be present a white 
cloud of albumin will immediately appear at the bottom of 
the tube, which can be readily seen on slight agitation. If 
the urine is slightly clouded it is best to add the powder to 
a small quantity of water in the test-tube, and dissolve it 
previous to the addition of the urine. The urine is then 
added carefully with the pipette so that the two solutions 
do not mix. At the line of separation of the two liquids 
a zone of coagulated albumin will be seen, when it is 
present. 




Bartley's Pocket Uri- 
nary Test Case., with 
Spirit Lamp. 



The Physicians' Manufacturing Supply Co., 140 Nassau St., New York. 



58 HOW TO EXAMINE FOR LIFE INSURANCE. 

SUGAR TEST. 

Formula : Indigo-carmine, I part, 

Sodium carbonate, 20 parts, 

Mix the dry powders and rub in a mortar. 
The indigo-carmine is a sulphindigotate of sodium, made as follows : Take 
pure indigo and rub into a thin, creamy paste with strong sulphuric acid ; add 
water in sufficient quantity to thoroughly dissolve the sulphate of indigo, neu- 
tralize with carbonate of sodium, filter, wash once with a solution of carbonate 
of sodium, dry, and then mix as above. 

To use this powder a small quantity is put into about a drachm of the sus- 
pected urine, and this is then heated to boiling. If sugar be present, the color 
is changed to green, violet, red and finally yellow. On agitating this yellow 
liquid the colors reappear in the reversed order. In testing for traces of sugar, 
only sufficient of the powder should be added to give a faint blue color to the 
urine. This test is delicate, is not affected by any other ingredient likely to be 
found in urine, and is permanent. These powders are sent with the case. 

MICROSCOPE. 

A microscopical examination of the urine is required by many 
companies for all risks above a certain amount, and, when possible, 
should also be made by the Examiner when a small trace of albu- 
min is found, or when the urine is of low specific gravity. This 
test, of course, requires a knowledge on the part of the Examiner 
as to exactly what is needed, and great care is necessary in making 
it. The urine should be collected in a chemically clean vessel, and 
should stand in a conical glass, covered, for at least twelve or 
more hours before examination, and then a small quantity should 
be drawn from the lowest portion of the glass by means of a chemi- 
cally clean pipette, and placed under the microscope on a glass 
which is absolutely clean, previously washed with alcohol and cov- 
ered with a glass cover treated in the same way. Several examina- 
tions should be carefully made, as in many cases possibly only one 
cast may be found in a field, and, indeed, several specimens may be 
examined without any being found at all. 

If the urine is very highly colored, the color may be due to 
the presence of blood, uric acid or bile, all of which should be 
carefully looked for ; the former, usually associated with albumin, 
can be detected by means of the microscope (which is the best test 
of all), the latter by means of allowing a few drops of urine and 
nitric acid to be placed separately upon a china plate and allowed 
to run together ; the line of contact, if bile is present, will show a 
variety of colors, from green, violet or blue to red. 



EXAMINATION OF THE KIDNEYS. 



59 



The blood corpuscles may be free, as in Figs. 10 and 1 1 or they 
may be in casts. The former will point to some irritation of the 
pelvis of the kidney, or of the ureters or bladder, due to gravel or 



Fig. io. 




Fig. ii. 



• <sj|& 



Shriveled blood corpuscles in urine (catarrh of 
bladder), with numerous lymph corpuscles 
and crystals of iriple phosphate X 350. 



5 ® 4 •• • • 



Colored and colorless blood corpuscles of 
various forms. 



malignant disease ; the latter to an inflammation or congestion of 
the kidney. In both cases albumin will be present in more or less 
amounts. Pus frequently is present with blood in the former case. 



Fig. 12. 




Forms of Uric Acid. 
1, Rhombic plates. 2, Whetstone forms. 3, Quadrate forms. 4, 5. Prolonged into points. 
6,8, Rosettes. 7, Pointed bundles. 9, Barrel forms precipitated by adding hydro- 
chloric acid to urine. 



An excess of uric acid, which will give a high color to the urine„ 
is noted by its appearance, the acid reaction, and also the presence of 



6o 



HOW TO EXAMINE FOR LIFE INSURANCE. 



uric acid crystals under the microscope (see Fig. 12). Normal urine 
should show slightly acid reaction by litmus paper. The acidity is 
not due to uric acid, but probably to the acid phosphate of sodium. 

The presence of uric acid in large amounts is important in con- 
nection with the history of gout, and gout sooner or later leads to 
interstitial nephritis. 

Rheumatism also has an important bearing upon probable lon- 
gevity, especially when the applicant has had frequent attacks and 
when the disease is hereditary. The urine in such cases may contain 
uric acid and urates in large amounts. Therefore, when uric acid or 
urates are found in quantity especial attention should be paid to the 
heart and arteries, and a careful search be made for albumin and casts. 

Urine alkaline from fixed alkali may be indicative of anaemia, 
chlorosis, exhaustion from overwork, care and anxiety. 

It is well to bear in mind that the coloring matter of the urine in 



Fig. 13. 




Oxalate of Lime. 
-b, Octahedra. c, Compound forms, d, Dumb bells. 



these cases of excess of uric acid may frequently give a slight red- 
dish tint to the urine during the test for sugar with Fehling's solu- 
tion, and the Examiner finds it difficult to decide whether this is 
due to the uric acid or a slight trace of sugar; but this can be 
definitely settled by means of the bismuth or the fermentation test. 

The presence of oxalate of lime in urine can be detected readily 
by the microscope (see Fig. 13), and when associated with a history 
of dyspepsia, may have some important bearing on the case ; so 
also would the presence of crystals which denote the fermentation 
of urine, either acid or alkaline (see Figs. 14 and 15). Especially 
are all these crystals of importance should the case present a 
history of nephritic colic or gravel, of disease of the prostate gland 
or bladder. 

Casts should be carefully searched for. They may be found in 
acute disease of the kidney and also in the chronic forms. They 



KX A MI NATION OF THE KIDNEYS. 



6l 



may be disassociated with the presence of albumin, the albumin 
appearing earlier or later in the disease. 

It is not necessary in this work to dwell upon the different 



Fig. 14. 




Deposit in Ammoniacal Urine (alkaline fermentation). 
A, Acid ammonium urate. B, Ammonio-magnesium phosphate. C, Bacterium ureae. 

varieties of kidney disease, and their diagnosis by means of casts, 
but all that is necessary is to show that their presence should 
invariably reject the applicant for insurance. 






-Ob 










y f /$i&>w kj?-«£ K &&?2/ * 






Deposit in " Acid Fermentations " of Urine. 
A, Fungus. B, Amorphous sodium urate. C, Uric acid. D, Calcium oxalate. 

The varieties of casts most usually found in urine are seen in 
the accompanying Figs. (16, 17, 18). They may be few in a field, 
and, indeed, several examinations may be made before a single cast 
is discoverable. The casts of least significance are the hyaline. 




62 



HOW TO EXAMINE FOR LIFE INSURANCE. 



The microscope will also reveal bladder epithelium, and in the 
female vaginal epithelium; of course, these would be of no import- 
ance whatever unless the question should arise as regards the 
difficulty of deciding between some forms of bladder epithelium 
and that which comes from the pelvis of the kidney. 



Fig. 16. 



A B C 





Fig. ii 



Hyaline Casts. 

B, With leucocytes. C, With 

renal epithelium. 



Epithelial Casts. 




Finely Granular Casts. 



It is well to bear in mind that urine that is preserved for micro- 
scopical examination should have a small quantity of salicylic acid 
added to it to preserve it, and this does not interfere with the 
examination. 



DISEASES OF THE GENITO-URINARY ORGANS. 

The applicant should also be questioned as to any disease affect- 
ing the urinary organs, cystitis, enlargement of the prostate gland, 
frequency of urination, especially at night, the history of stricture, 
diseases of the testicles, stone in the bladder, enlargements of the 
inguinal glands, chancre, and all that pertains to syphilis. 

The applicant should always be carefully questioned for the evi- 
dences of constitutional syphilis, if there is the slightest suspicion 
of it, especially if he acknowledges having had chancre. The 
Examiner should remember the importance of sore throat, alopecia, 
of nocturnal pains in the bones, and of an eruption which does not 
itch. It is simply necessary to call the attention of the Examiner 
to these matters, which might otherwise be overlooked. 



NERVOUS SYSTEM. 63 

CHAPTER XIII. 

NERVOUS SYSTEM. 

During the course of the examination the Examiner must bear 
in mind the importance of the nervous system as affecting life in- 
surance. The following symptoms would show some disease, and 
should be carefully looked into: "Slowness of speech, sentences 
broken off or uncertain, deficiency in memory,. agitated lips, tremu- 
lous tongue, or tongue drawn to one side, inequality of pupils, 
double sight, step defective in balance." 

The applicant should be asked to stand with eyes closed, so that 
the Examiner may detect locomotor ataxia ; all evidences of paralysis 
should receive careful attention. Bell's palsy, or ordinary facial 
paralysis from cold, should be noted as distinct from paralysis of 
central origin. Facial palsy is frequently attendant upon disease 
of the middle ear. Every applicant should be carefully questioned 
in regard to disease of the ear, both acute and chronic. Suppura- 
tion of the middle ear may cause death (i) by caries of the temporal 
bone and its consequences, (2) by septic phlebitis, (3) by tubercu- 
losis. Chorea should be noted, and local peripheral palsies should 
also be differentiated from those of central origin. Neuralgia, head- 
ache and vertigo should be most carefully investigated, and the 
results stated on the examination paper, with special reference to 
epilepsy in its minor and major form ; the attacks of neuralgia, 
should be carefully explained, particularly if they show any evi- 
dences of angina pectoris. 

The abuse of narcotics, tobacco, or drink of any kind should 
never be absent from the mind of the Examiner, as such cases 
frequently come before him for investigation ; if the least suspicion 
should arise as regards the excessive use of stimulants, the 
Examiner should closely question the applicant's past habits, and 
endeavor as far as possible to get a correct statement as regards the 
same, and note whether they have produced any lesion of the 
nervous system. Syphilis often shows its effects upon the nervous 
system when other manifestations of it are absent, and these must 
always be carefully looked for. Eccentricities, mental peculiarities 
should be noted; so, also, any history of melancholia, nervous 
prostration, insanity, or anything that might lead to suicide. 



64 HOW TO EXAMINE FOR LIFE INSURANCE. 

CHAPTER XIV. 

EXAMINATION OF WOMEN. 

Most Companies at the present day insure women, and some at 
the same rates as they do men, and hence it becomes necessary 
that a most careful examination should be made of women, especi- 
ally in regard to those diseases which are of vital importance. It 
is an extremely difficult matter to give the same thoroughness of 
examination to a woman as to a man, but an Examiner should not 
hesitate, should he find it necessary, to make a thorough examina- 
tion, in order to satisfy himself that the applicant is in every way 
insurable. 

Women are much more liable to phthisis than men, and, there- 
fore, stress should be laid upon the examination of the lungs for 
the detection of the earliest evidence of pulmonary disease. (See 
also Chapter VIII.) 

It has been taught that physiologically women breathe with 
their apices, and that in men the breathing is more abdominal ; 
but T. J. Mays has shown that in the Indian girl, whose thorax 
has never been imprisoned by corsets, the respiratory movement is 
the same as that in men. This is interesting from a life insurance 
point of view. 

Diseases of the breast are often of great importance, and as 
cancer of the breast is most apt to occur about the time of the 
menopause, the Examiner should especially inquire into any 
tumors or tenderness in that region, the presence of enlarged 
glands in the axilla, and note any evidence of cachexia ; he should 
also inquire in regard to cancer elsewhere, especially of the uterus ; 
he should inquire particularly into the menstrual function, and 
note on his paper any points that are of importance. If the appli- 
cant has reached the time of the menopause, and is still " unwell," 
the Examiner should inquire particularly into the character of the 
discharge, and the length of time it exists, as it is known that one 
of the most important evidences in favor of cancer of the uterus 
is the prolongation of the menopause beyond its normal period, 
possibly after 50 years of age. 

The Examiner should also inquire into enlargements of the 
abdomen, tenderness in that region, the presence of tumors, either 
solid or fluctuating. He should inquire particularly into the char- 



SUMMARY. 65 

acter of the husband, if the applicant be married, and also into the 
subject of her child-bearing. 

The questions will require tact on the part of the Examiner, 
and should he elicit answers which are not perfectly satisfactory, 
it is well for him before he sends his report to the Home Office, 
to consult the family physician, and obtain his views in regard to 
the case. 



CHAPTER XV. 

SUMMARY. 



Of course the question as regards the acceptance- of the risk 
depends upon the decision made at the Home Office of the Com- 
pany, and it is the Examiner's duty to make his statements clear and 
correct, in order that they may form the proper basis for a decision. 

Having now completed the paper, before the applicant leaves, the 
Examiner should carefully read over the paper and see that every 
question has been thoroughly answered, that the signatures are in 
their proper places, and the instructions from the Medical Depart- 
ment of the Company should be referred to, so that no further 
correspondence will be necessary from the Home Office. This is a 
matter which, from a business point of view, is a most important 
one, and it is one to which Examiners, as a rule, pay the least atten- 
tion. There are certain legal requirements that go to form a contract, 
and an application for insurance is a contract with the Company, 
and these have to be fulfilled ; and though they may appear to be 
trivial and of little consequence, yet, from the Home Office view, 
they are most important, in order that all questions may be settled 
at once before a policy is issued, so as to prevent any contention 
after the policy has been issued or upon the death of the applicant. 

If the Home Office requires that the examination blank shall be 
mailed direct to the Medical Director immediately upon its comple- 
tion, this should be done before the Examiner allows his attention 
to be called away by other work. 

The little matters that appear trifling to an Examiner assume 
an importance when received at the Home Office which the 
5 



66 HOW TO EXAMINE FOR LIFE INSURANCE. 

Local Examiner cannot estimate, and frequently give rise to delay 
which may interfere seriously in the placing of the policy, and it 
will annoy the agent, and consequently give rise to a feeling which 
prevents that harmony that should exist between all branches of 
Life Insurance. A good Agent will never complain that a risk is 
declined if the Examiner has done his conscientious duty and the 
applicant is not fit for insurance, but where the placing of the policy 
has been interfered with by carelessness or inattention on the part 
of the Examiner, complaints will naturally arise and create unfavor- 
able impressions at the Home Office. 



PART II. 



INSTRUCTIONS 



TO 



MEDICAL EXAMINERS, 



AS ISSUED BY THE 



VARIOUS LIFE INSURANCE COMPANIES. 



JEtna. Life Insurance Company, Hartford, Conn., . . G. W. Russell, M, D. 

^Berkshire Life Insurance Company, Pittsfield, Mass., F. K. Paddock, M. D. 

Brooklyn Life Insurance Company, New York City, 

Connecticut General Life Insurance Company, 1 n/r a . n/r ^ 

Hartford, Conn, > \M Starrs, M.D. 

Connecticut Mutual Life Insurance Company, Hart- 1 ~ „ c , ., , n/r ^ 
r j /- r Geo. K. bfiepnerd, M. D. 

Equitable Life Assurance Society of the U. S., New ") E. W. Lambert, M. D. 

York City, j Edward Curtis, M. D. 

*Germania Life Insurance Company, New York City, Chas. Bernacki, M. D. 
Home Life Insurance Company, Brooklyn, N. Y., . . 
John Hancock Mutual Life Insurance Company, \ w h u/ „ M n 

Boston, Mass., / ^ ran * WeUs > m ' "' 

Life Insurance Company of Virginia, Richmond, Va., H. Cabell Tabb, M. D. 

Maryland Life Insurance Company, Baltimore, Md, F. Donaldson, M. D. 

Massachusetts Mutual Life Insurance Company, ^ ^ lxr ri ,. n/r ^ 
Springfield, Mass., > \ F W Cha P m, M. D. 

Michigan Mutual Life Insurance Company, Detroit, ~) ^ ~ r , n/r ^ 
Mkh ^ ' ' | Henry F. Lyster, M. D 

Mutual Benefit Life Insurance Company, Newark, 1 ^ dg % r S olde ^ M ' D ' 



-\. 



N - J #> J Jos. C. Young, M. D. 

Mutual Life Insurance Company of New York, New \ G. S. Winston, M. D. 

York City, ) W. R. Gillette, M. D. 

National Life Insurance Company, Montpelier, Vt., A. B. Bisbee, M. D. 

New England Mutual Life Insurance Company, \ T i zr n/r r, 

Boston, Mass., )J ohn Homam > M D ' 

New York Life Insurance Company, New York City, } TZnZ^M.'p. 
Northwestern Masonic Aid Association, Chicago, \ G r a I r M D 

Northwestern Mutual Life Insurance Company, \ t . n/r ~ . , , n/r A 
Milwaukee, Wis., } Lewis McK ™sK M. 3. 

Penn Mutual Life Insurance Company, Philadelphia, \J. M. Keating, M. D. 
Pa., ) O. P. Rex, M. D. 

Phoenix Mutual Life Insurance Company, Hartford, 1 , TJTr D n/r ^ 

~ ' ' V A. W. Barrows, M. D. 

Conn. , J 

-Provident Life and Trust Company, Philadelphia, \ j., w'star M D 

Pa., / 

Provident Savings Life Assurance Company, New") ^ , c n . n/r n 
^ , -,.. ' y rrank 6. Grant, M. D. 

V ork City, J ' 

*State Mutual Life Assurance Company, Worcester, \ Thos. H. Gage, M. D. 

Mass., ) Albert Wood, M.D. 

^Travelers' Life Insurance Company, Hartford, Conn., G. Pierrepont Davis, M. D. 
Union Central Life Insurance Company, Cincinnati, \ w k D ' M D 

Ohio, j m ' ' ams ' ' ' 

Union Mutual Life Insurance Company of Maine, \ ta Foster M. D 
Portland, Maine, J ' 

*United States Life Insurance Company, New York \ r p M unn m n 
City, ] J - • ' > 

Washington Life Insurance Company, New York City, Jno. W. Brannan, M. D. 



THOSE COMPANIES MARKED WITH AN ASTERISK ISSUE NO SPECIAL INSTRUCTIONS TO THEIR 
MEDICAL EXAMINERS. 



jETNA life insurance company. 

EXTRACTS FROM INSTRUCTIONS TO MEDICAL EXAMINERS. 

The application of the person to be examined should always be in the hands 
of the Examiner, and carefully read, before the examination is made. If any- 
thing of past or present disease is noticed, special attention should be given to 
it, and if there appears to be anything of an hereditary disease in the family 
history, the Examiner should inquire concerning it thoroughly, though the 
applicant himself may present no indications of the same ; and the inquiries 
should be extended to both branches of the applicant's family. 

An experience of many years leads us to place much value upon the family 
record ; it is of more importance, we think, than is usually attached to it by 
Examiners, many of whom, we know, have no hesitation in recommending for 
insurance those who have had parents and other relatives die from consump- 
tion or allied diseases. Notwithstanding all our precautions, we find our largest 
mortality in diseases of this character. The present personal condition of the 
person to be insured seems in these cases wholly to engross or over-ride all 
other considerations in the mind of the physician. 

It is not thought necessary to give special and explicit instructions for exami- 
nations. If the Examiner is well qualified, all necessary inquiries will occur to 
him. But it is well to remember that the applicant for insurance regards him- 
self usually as occupying a very different position from that of an ordinary 
patient ; in the latter he is often disposed to magnify his infirmities, while in 
the former he is more likely to conceal them. 

The sound common-sense of the medical man is especially necessary for an 
Examiner ; whatever there is of doubt in any case, let it be given in favor of 
the Company. We are not so anxious to do business that we will accept uncer- 
tain or doubtful risks. 

Again, let us point out to the Examiner that he is the employee of the Com- 
pany ; to the Company he is responsible, and to no one else ; he is paid the 
same fee whether a favorable or unfavorable report is made, and will be con- 
tinued in his position if he is skilled in his profession and is careful in his 
examinations. And we wish to impress upon him the necessity of not alone 
exercising his skill, but also his independence in expressing his opinions. His 
integrity must be above reproach ; no outside influence whatever should be 
allowed to sway him ; all the facts should be carefully reported, and his deci- 
sion given with the whole case fairly in his mind, considering the present con- 
dition, the occupation, location, habits, family history, etc. 

Our losses from the direct or indirect influence of the use of alcoholic stimu- 
lants are larger than they should be. No one can persist in the habitual use of 
these agents without having the pi'obabilities of his longevity impaired, and it 
is therefore of great importance that the Examiner should inquire carefully 
concerning the habits of the applicant. This may be done delicately without 
offence ; but often the evidences of habitual stimulation are apparent enough. 
No offence ought ever to be taken, for life insurance is a business to be guarded 

6 9 



JO HOW TO EXAMINE FOR LIFE INSURANCE. 

like other business matters, and must be pursued under the ordinary, and well- 
established guards of safety, if it is to be made successful. 

All cases where pregnancy exists should be declined until after recovery 
from confinement, and great care should be exercised in recommending 
females between the ages of forty and fifty, or until the "change of life" is 
fully past. 

While deaths frequently occur from "childbirth," "general debility," 
"dropsy," "change of life," and the like, yet it is believed that these are 
sometimes reported as the primary causes of death, when the true statement 
should have been consumption or some hereditary disease. " Dropsy" is but 
a symptom, and if a member of a family die in childbed, it should be supple- 
mented with " strictly puerperal," as an explanation. 

Let Examiners bear in mind that the lately-introduced term of "heart 
failure," as the cause of death, is most comprehensive, and yet indefinite and 
unsatisfactory ; all such reputed cases should be carefully inquired about, and 
the true disease discovered, if possible. 

Please communicate with the Home Office directly, whenever there is a 
necessity. You can do so confidentially. 

Finally, write legibly, with black ink, expressing yourself clearly and with 
as much positiveness as is possible or prudent. 

EXTRACTS FROM INSTRUCTIONS TO AGENTS. 

Medical examinations must be made by the regular Examiner of this Com- 
pany ; none other will be accepted. 

While the Medical Examiner should be a friend of Life Insurance in order 
that his influence may not oppose the efforts of the Agent, he is not expected 
to assist in soliciting, nor to act otherwise than in a purely professional capacity. 
The fee for examination is $2.00 in the country, varying to not exceeding $3.00 
in the larger towns and cities ; and when an examination of the urine is re- 
quired, the fee for the entire examination should not exceed $5.00. The Com- 
pany will not pay more than the fees here named, and will not pay traveling 
expenses. Medical Examiners should not be employed to examine a parent, 
brother, sister, wife, child, or other near relative ; nor should an Examiner be 
employed who is a near relative of the Agent ; but in such cases some other 
regularly appointed Examiner of the Company should be called. 

Applications from persons who are ruptured will be accepted only on con- 
dition that the insured shall wear a truss. Objection is sometimes made to this 
requirement, on the ground that the rupture is so slight as to render a truss un- 
necessary. Slight ruptures are regarded by many physicians as being quite as 
likely to become dangerous as larger ones, and consequently the above require- 
ment will be adhered to in all cases. 

The Company decline to issue policies on the lives of persons older than 
sixty years, or to exchange an old policy for a new one on the life of a person 
beyond that age, except when renewing the term of a Renewable Term policy, 
as provided therein. 

Neither will policies be issued on the lives of persons who have nearly or 
quite lost the sense of sight or hearing, nor, as a rule, upon those who have lost 
a leg. 



/ETNA LIFE INSURANCE COMPANY. 7 1 

Applications on the lives of females are not desired, unless they arc unex- 
ceptionable, both with reference to family history and the applicant's own 
health and condition. No such application will be accepted during 
PREGNANCY. In the medical examination of females, a special certificate, on 
a blank furnished for the purpose, is required in connection with the regular 
medical certificate, and the Company limits the amount of insurance upon 
such lives to $3000 each. 

All applicants must have been successfully vaccinated before the risk will be 
accepted. If this has not been done before the application is written, a certifi- 
cate from the examining physician must thereafter be furnished, showing the 
applicant to have been successfully vaccinated before a policy will be issued. 

#5^* Before writing an application for insurance, or before requiring a 
medical examination, the Agent should make some general inquiries relative to 
the family and personal history, the occupation, etc., of the applicant. These 
may be sufficient to determine that the risk is not insurable, so that unavailing 
labor and expense can be avoided. 

As a rule, those persons engaged in exceedingly hazardous occupations will 
not be accepted for insurance, nor those who desire to travel to uncivilized 
countries, or to latitudes of extreme heat or cold. 

It is believed that excessively large or small persons have not so good a 
prospect of longevity as those of nearer medium size. No application should 
be made for insurance on the life of a person weighing over 225 pounds, how- 
ever well proportioned or unexceptionable in other respects the person may be. 



THE BROOKLYN LIFE. 

INSTRUCTIONS TO THE MEDICAL EXAMINERS. 

The object of every examination for Life Insurance is to discover if there is 
any existing or predisposing cause to prevent the candidate from reaching what 
is known to be an average age. 

Every Medical Examiner should understand that when he recommends a 
risk as safely assurable for the whole term of life — whether in limited payments 
or on ordinary life — he is presumed to express his decided opinion that the sub- 
ject not only is in present sound health, but that he also has a fair chance and 
prospect of living out his " Expectation." What this Expectation is maybe 
learned from the following table : — 

EXPECTATION BY AMERICAN TABLE. 

(Standard Adopted by N. Y. State Insurance Department.) 

The Expectation at any age is the average after lifetime of all the persons at 
that age, reckoned to the end of the year that each may die. 



AT THE 


HAS A FAIR 


OR TO THE 


PRESENT AGE. 


CHANCE TO LIVE. 


AGE OF 


IO 


48 years longer. 


58 years. 


15 


45 " " 


60 " 


20 


42 " 


62 " 


25 


38 " " 


63 " 


30 


35 " 


65 « 


35 


31 " 


66 " 


40 


28 " 


68 " 


45 


24 « 


69 « 


50 


20 " « 


70 " 


55 


17 « 


72 " 


" 60 


14 « 


74 " 


65 


11 " " 


76 « 


70 


8 " 


78 « 


75 


6 " 


81 " 


80 


4 « 


84 " 



That is, a man recommended on the Life plan, age 25, is judged by the 
examining physician to possess a fair chance of living to the age of 63 ; this 
applies not only to ordinary life, but to Life in 5, 10, 15 or 20 payments — in 
fact, on'any Life plan the Expectation should be considered as probable to be 
attained. 

While it is impossible to say that any individual so selected will certainly 
attain to the age assigned in the table, yet it is beyond question that those who 
have inherited good constitutions, live temperately, in healthy localities and 
follow occupations not specially hazardous, will live longer than those differ- 

73 



74 HOW TO EXAMINE FOR LIFE INSURANCE. 

ently circumstanced. It is this difference which forms the basis of life insur- 
ance, and hence the importance of selecting only those who approach as 
near as possible to a healthy standard. To assist the Medical Examiner 
in performing this duty, and to point out the special sources of danger, 
deception and error, your attention is specially requested to the following sug- 
gestion : — 

It is of primary importance that the Examiner should possess a good medi- 
cal education, and in addition thereto he should have attained that maturity of 
judgment which follows close observation and reflection upon it. He should 
take sufficient time to make his examinations (even repeating them if neces- 
sary), and record all the facts and conclusions with care and fidelity, continu- 
ally bearing in mind that it is the interest of every applicant for life insurance 
to make the best exhibit of his or her own case, and, if so inclined, to under- 
state or withhold important facts, either in their own or family history. Thus 
to be duped, compromises the character of the Examiner for penetration and 
capacity, against which special vigilance is the only protection. 

PREDISPOSITION TO DISEASE. 

This is carefully to be considered in reference to tubercular disease — 
especially that form of it known as pulmonary consumption — and also to 
diseases of a cancerous or malignant nature ; in a word, those which are 
notoriously transmissible from parent to offspring. Should both parents of the 
applicant have died from these causes — or only one of them, while several 
brothers, sisters, or near relatives have developed similar diseases — the predis- 
position must be considered sufficient to cause rejection ; unless applicant shall 
manifest, on careful examination, a thoroughly sound condition of all the vital 
organs, and shall exhibit satisfactory physical development as to weight, size 
and height, shall have lived temperately, and reached at least the age of 35 
years, and shall have heretofore enjoyed uniformly good health. Under such 
circumstances, a Policy of moderate amount may be granted to an individual 
following a healthy vocation. In case of a strongly inherited predisposition to 
cancerous diseases, it should be remembered that such diseases do not often 
develop themselves until the afflicted is 40 or 50 years of age ; so that a Policy 
on the Endowment plan, with 15 years or less to run, may be more safely 
granted to such an applicant between the ages of 20 and 30 than when older. 
Again, it must not be forgotten that strong predisposition to disease may 
be acquired through accidents and violent injuries, severe and repeated attacks 
of inflammatory disease, fever, rheumatism, profuse hemorrhages, unhealthy 
residences and employments, combined with irregular or bad habits in eating 
and drinking ; the immoderate use of tobacco, opium and other narcotics ; pro- 
tracted dyspepsia, obstinately constipated bowels, and a torpid skin, are also 
frequent preludes to confirmed and fatal diseases. Special inquiry should be 
instituted if the Examiner has the slightest suspicion of syphilis ; loo£ well for 
secondary symptoms, and the effects of specific treatment on the general 
condition. 

When examining those who have passed the middle period of life, remember 
the tendencies to fatty degeneration in the muscles of the heart, in the coats of 
the great vessels, causing aneurisms, and in those of the brain, tending to apo- 



THE BROOKLYN LIFE. 



75 



plexy. The existence of "the arcus senilis 
of these conditions very probable. 



in the eye renders some or all 



FEMALE RISKS. 

The ascertained fact that female risks have hitherto proved unprofitable ren- 
ders them undesirable as a class. Parturition and its attending complications 
largely increase the mortality previous to the age of 50. At or beyond that 
period cancerous diseases of the breast, uterus and its appendages, make their 
appearance, and are to be rigidly inquired after. No false delicacy should ever 
prevent the Examiner from instituting the most searching investigation if any 
suspicion exists in his mind, and the case should be rejected if the necessary 
examination is refused. In all cases of pregnancy defer the examination until 
the recovery from confinement is complete. 

PERSONAL EXAMINATIONS. 

Before a party is examined, his application should be completed and in the 
hands of the Examiner. When this cannot be had before the examination 
the certificate should be retained by him until the papers are complete, so that 
the final answer may be made in view of all the facts in the case. 

If the party has been recently ill always wait until recovery is perfect. 

There are certain general relations established between the organs and the 
functions of the human body, forming standards from which any marked varia- 
tions (particularly if sudden and rapid) should excite suspicion. Thus the proper 
relative weight of the body to its height may be estimated from the following 
table :— 



Height. Weight. 

5 ft. 1 in. 120 lbs. 

5 " 2 " 125 " 

5 " 3 ' : 130" 

5 " 4 " 135 " 

5 " 5 " 140" 

5 " 6 " 143 " 



Height. 
5 ft - 7 in. 

5 « 8 « 

5 " 9 " 
5 " 10 " 

5 " 11 " 

6 " 00 " 



Weight. 
145 ^S. 
I48 " 

155 " 
l6o " 
I6 5 « 
I70 " 



Excessively tall or heavy people are not so long lived as those of medium 
stature and weight. 

The capacity of the chest indicates the relative condition and vital power of 
its important contents. The Examiner should be particular to give the measure- 
ments in inches, taken under the vest and on a line just below the nipples — on 
full inspiration and forced expiration. The average circumference of the chest, 
when comparatively free from ^air, varies from 32 to 34 inches. The average 
expansion should be between 2 and 4 inches, and nothi7ig below 2 inches should 
ever be accepted. 

The relation between the frequency of the pulse and the general condition 
is a well-known standard. Thus a pulse below 60 per minute, in a young sub- 
ject, should excite suspicion ; equally so a pulse which persistently, and under 
repeated favorable conditions, continues to beat over 90 per minute. Other 
qualities of the pulse — as to regularity, intermissions, strength, etc. — must be 
carefully stated. Then, again, the relation between the pulse and respiration 
gives highly important information. This, in a healthy subject, may be esti- 
mated at about 1 respiration to every 4 beats of the pulse. As death from 



j6 HOW TO EXAMINE FOR LIFE INSURANCE. 

disease of the respiratory organs forms so large a percentage in the list of mor- 
tality, it is impossible for the Examiner to be too careful, not only in estimating 
the constitutional tendencies already referred to, but in making his physical 
explorations of the chest. This should always be very lightly covered, so that 
by applying the hands to its surface you may observe whether the expansion is 
free, full and alike on both sides. Carefully remark the spaces below the cla- 
vicles — whether they are depressed, and either dull or flat on percussion. Note 
the breathing there ; the respiratory murmur should be clear, soft, regular, and 
only heard on inspiration. If it is heard on expiration, and has a wavy, jerking 
or irregular sound, and if accompanied with a click, rattle or rale, you will 
probably find some cough, haemoptysis, expectoration, and other indications of 
"consumption." If the party is thin, has feeble digestion and irregular bowels, 
is easily affected by atmospheric changes, producing cough and catarrhal affec- 
tions of the mucous passages, especially chronic disease of the throat with 
huskiness of voice — when these symptoms coexist with a quick or chorded 
pulse, look well to the family history and the condition of the lungs. Remem- 
ber such predisposed people think and speak lightly of their symptoms, and are 
often very ready with explanations of them ; but if such indications exist, even 
in A remote degree, you must be exceedingly cautious in recommending risks. 
Another condition to be specially observed is an unusually sonorous resonance 
on percussion over the whole or a large portion of the thorax. This is usually 
accompanied with an altered respiratory murmur, and, if attended with difficulty 
of breathing, indicates that the air cells are dilated, and the party has asthma. 

The organs of circulation next command careful attention. Mark whether 
the heart occupies its normal position — if its apex beats about one inch below 
and to the left of the left nipple. Observe whether there is any intermission or 
irregularity in the beat ; whether gentle or violent, and whether the impulse 
against the chest is coincident with the first sound. Carefully listen for any 
bruit, rough sound or bellows murmur, which indicate that the valves of the 
heart have been injured by disease, and are thereby. obstructed. These altered 
sounds of the heart you will particularly look for after severe or repeated attacks 
of rheumatism before the age of 30. When existing for any length of time, 
hypertrophy of the muscular walls of the organ will have taken place, to com- 
pensate for the increased difficulty in driving forward the obstructed or regurgi- 
tative column of blood. Aneurisms or other tumors, if existing, and sufficiently 
advanced, will manifest themselves by such disturbance of the organs of respira- 
tion and circulation as scarcely to fail in challenging immediate attention. 

The condition of the urinary organs is very apt to escape inquiry. Long 
standing strictures, calculi, and enlargement of the prostate gland seriously 
compromise the functions and structure of the bladder, which in turn lead to 
fatal disorganization of the kidneys. Disease of the latter organs is a frequent 
direct or remote cause of death. When there has been persistent pain in the 
back, accompanied with a puffy or slightly cedematous condition of the face, it 
is always well to make some examination of the urine. It will be sufficient to 
take the specific gravity with an ordinary urinometer. By comparing the 
number on the stem to which the instrument sinks, with the corresponding 
number in the annexed table, you will see at a glance how far the specimen 
varies from a healthy or safe standard. 



THE BROOKLYN LIFE. 



77 



SP. GR. 



FLUIDS EXAMINED. 



DISTILLED WATER. 



IO0 5 | Average in Bright's disease 1013 

l Mav cto as low as 1 004 



1015 J 

1020 
1025 

1030 

I035 
1040 

I045 
1050 

I055 
1060 



May go as low as 1004 



Average limits of healthy urine. 



Limits of Diabetic Urine. 

Average 



1040 



If after boiling in a test tube the urine becomes turbid, and does not clear up 
on the addition of a few drops of nitric acid, while the specific gravity comes 
within the limits of Bright's disease, the case should be rejected. 

The state of the brain, nervous and muscular systems may be ascertained 
by noting the general appearance and expression of the face, manner of speech, 
the gait in walking, or the want of control over any particular set of muscles, 
exhibited by tremors or irregular movements. Affections of one or more of the 
special senses — sight, hearing, taste, smell and feeling — attended with dizziness 
and confusion of mind, especially when following accidents, are the forerunners 
of insidious and fatal diseases of the brain. It is always important to inquire 
into the character of any severe injury or attack of illness, with a view to dis- 
cover any effects upon the organs involved, the general health and prospect of 
life. 

The functions of digestion and nutrition should be thoroughly examined to 
discover any indications of latent disease. Note the presence of hemorrhoids, 
tumors, fistulas, and if there is hernia or rupture which is reducible, insist on the 
constant use of a proper truss. 

The habits of the party as to the use of alcoholic stimulants, tobacco and 
opium, should never be neglected ; and although the personal appearances, on 
examination, may furnish the best testimony, indirect evidence on these import- 
ant points should be sought from friends or acquaintances. 

Observe that the results of your investigation accord with the statements 
made in the application of the party examined, and then let the party sign his 
or her name to insure their identity. 

From these general instructions we may condense the following 



CAUSES OF REJECTION : 

1st. When both parents have died of pulmonary consumption. 

2d. When one parent and one or more offspring have died of the disease, 
unless the applicant has attained the age of 35 years, and exhibits a robust 
condition, entirely free from all discoverable indications of disease. 



y8 HOW TO EXAMINE FOR LIFE INSURANCE. 

3d. Intermissions and irregularities in the action of the heart, abnormal 
sounds or symptoms of hypertrophy, aneurism, ossification of the bloodvessels, 
habitual cough, difficulty of breathing and asthma. 

4th. If the pulse is above 90, after due rest and repeated trials. 

5th. When the applicant has been affected with apoplexy, paralysis, epilepsy, 
insanity, impairment of the senses and voluntary motion, a shuffling and un- 
certain gait, rapid tendency to obesity, with other symptoms indicating softening 
of the brain. 

6th. Serious or protracted diseases of the liver and digestive organs, impairing 
the general health. 

7th. Destructive diseases of the bones of the spine, hip, knee or other large 
joints, with abscesses, lumbar or psoas abscesses, unless a long period of entire 
and satisfactory cure has elapsed. 

8th. The existence of open ulcers, scrofula, frequent attacks of erysipelas 
or colic, gout, fistulas in ano or perineo, irreducible hernias, and important 
tumors. 

9th. Diseases of the kidneys, bladder, gravel, calculi, secondary syphilis, 
blindness, permanent strictures, and amputation above the knee or elbow joints 
for disease. 

10th. All cancerous or malignant diseases — even when doubtful or suspi- 
cious — including those of the stomach, intestinal canal and rectum. 

nth. All cases where, after any illness or injury, its effects are perceptible in 
permanent loss of vigor in the constitution. 

1 2th. Whenever the Medical Examiner has a well-founded doubt, or has 
good reason to suspect the truthfulness or honesty of the applicant, it is his duty 
to decline the risk. 

The Company desires only such risks as are in good, sound health. No 
impaired risks accepted under any circumstances. 

A party in perfect health, but with an objectionable family record, may be 
recommended by the Examining Physician for an Endowment Policy having 
as many years to run as he may think the risk is assurable for. 

But no risk to be taken for the whole term of life — whether ordinary Life or 
Life in one, five, ten, fifteen or twenty payments — unless he or she is judged to 
have an equal chance with all others of the same age of living out the full 
Expectation according to that age. 

Of course, any person with a hereditary predisposition cannot be judged to 
have as fair a chance to live out the Expectation as one with a good family 
record. 

"A STEP IN ADVANCE!" 

In the determination of the presence of disease, no medical practitioner of 
the present day who values his standing, can afford to dispense with the use of 
the thermometer. Throughout the world, all high professional authority in 
dealing with the professedly sick, thoroughly appreciate and confidently invoke 
the aid of this simple instrument. Why, then, should it be ignored and neg- 
lected in life insurance examinations, upon the results of which depend the 
making of contracts involving thousands upon thousands of dollars. 

Many an applicant may be laboring under the slow and stealthy effects of 
disease, yet scarcely conscious or even suspicious of the fact, simply because 



THE BROOKLYN LIFE. 79 

the bodily disturbances have not yet declared themselves by such symptoms or 
physical signs as are readily recognized. 

It is important, then, for the practitioner who would shun the same sources 
of deception and delusion, to know that any departure from the normal tem- 
perature (98 to 99 Fahrenheit) of only a few degrees, which recurs daily or 
after moderate exercise, and does not readily subside, should awake sufficient 
suspicion to induce a repetition of the observation, and, if the abnormal tem- 
perature is found persistent, to make it the subject of special report. 

In this connection, it is important to be aware that by far the largest per- 
centage of premature losses are resultant from pulmonary and allied forms of 
disease, due to the "tubercular" and other well-known constitutional tenden- 
cies, either hereditary or acquired. We cannot, therefore, too seriously ponder 
the practical teaching of Prof. Sidney Ringer, when he says, " that by means 
of the thermometer we can diagnose tuberculosis and tuberculization long 
before the physical signs and symptoms are sufficient to justify such diagnosis." 

This statement is equally reasonable and correct in regard to many other 
insidious morbid states, not as matters of opinion or theory, but of experimental 
observation ; so that we may lay it down as positive, that no serious perversion 
of the physiological processes of the body can be progressively going forward 
without indicating the fact by an unusual departure from the normal tempera- 
ture ; and, likewise, that the clinical thermometer properly employed will un- 
erringly reveal this information. 

For these cogent reasons (to which many others might be added) the study 
and employment of this instrument is earnestly and confidently urged upon 
the medical examiners of the Brooklyn Life, as an invaluable assistant in esti- 
mating those bodily conditions which lead up to the premature and extra vital 
limitations of those upon whom you may be required to furnish an opinion. 
It shields the Examiner from serious and often fatal error, by assisting his judg- 
ment with positive information instead of mere opinion, and thus appeals 
directly to his own personal interest by establishing his professional capacity. 
To a physician, a good thermometer is of infinitely more value than a watch. 
To persistently dispense with its use under the light of present indisputable 
evidence in its favor, is about equivalent to the practice blindfolded of a profes- 
sion which demands all the assistance which art and intelligence can furnish. 



CONNECTICUT GENERAL LIFE INSURANCE 
COMPANY. 

INSTRUCTIONS TO THE MEDICAL EXAMINER. 

i. In accepting the appointment of Medical Examiner for the Company, 
the physician should realize that he thereby becomes an employee of the Com- 
pany. To the Company alone is he responsible, and in making his examina- 
tions, regard should be had, alofie, to the interests of the Company. He is paid 
the same fee, whether a favorable or an unfavorable report is made, and he will 
be continued in his position if he is skilled in his profession, and is careful and 
conscientious in his examinations. 

And we wish to impress upon the Examiner the necessity, not only that he 
should use his utmost skill and most careful judgment in the examination, but 
also that he should exercise the most perfect independence in his statement of 
facts and expression of opinion. His integrity must be above reproach, and 
no outside influence whatever should be allowed to sway him. All the facts 
should be carefully reported, and his decision given with the whole case fairly 
in mind, considering the family history, present condition, location, habits, etc., 
of the applicant. It will be well, however, for the Examiner to remember that 
the applicant for insurance usually regards himself as occupying a very different 
position from that of an ordinary patient. In the latter, he is often disposed to 
magnify his infirmities, while in the former he is likely to conceal them as far 
as he can, and their discovery may require special vigilance on the part of the 
Examiner. 

2. Many Examiners feel their whole duty to the Company has been per- 
formed, when they have thoroughly examined into the prese?it personal 
condition of an applicant. This is an error, and the Examiner should bear in 
mind that there are in every case three very important general points to be 
considered : — 

i. Family History. 

2. Personal History. 

3. Present Personal Condition. 

As full and specific information relative to each of these points, as is possible 
to obtain, should always be furnished. 

3. An Examination should not be made in any place, where, from noise or 
confusion, the sounds of the heart and respiratory murmur of the lungs cannot 
be clearly and distinctly heard : nor should it ever be made hurriedly, or when 
from any cause, the Examiner cannot carry it through leisurely and composedly. 
It will be better to postpone the examination rather than make ah imperfect and 
unsatisfactory one. 

4. The Application of the person to be examined, fully completed, should 
always be in the hands of the Examiner, and carefully read, before the exami- 
nation is made. If anything of past or present disease is noticed, special atten- 
tion should be given to it, and thorough investigation made. If there appears 

6 8l 



82 HOW TO EXAMINE FOR LIFE INSURAN'CE. 

to be anything of an hereditary nature in the family history, the Examiner 
should particularly and thoroughly inquire into it, even though the applicant 
himself may present no indications of the same. The inquiries should be ex- 
tended to both branches of the applicant's family ; and all general and indefinite 
statements regarding deaths should be explained, as "childbirth," "effects of 
childbirth," " change of life," " accident," " debility," " old age," etc. 

If ignorance of family history is pleaded, some proximate idea of the causes 
of death should be gleaned by the Examiner and stated as such. 

An experience of many years leads us to place much value upon the family 
record. It is, we think, of more importance than is usually attached to it by 
Examiners, many of whom, we know, have no hesitation in recommending for 
insurance those who have had parents and other relatives die from consumption 
or allied diseases. Yet with all our precautions, we find our largest mortality in 
diseases of this character, and in these cases the present personal condition of 
the person to be insured seems to have wholly engrossed or overridden all 
other considerations, in the mind of the physician. 

5. Every effort should be made by the Examiner to satisfactorily ascer- 
tain the personal habits of life of the applicant, both past and present. There 
is no greater foe to Life Insurance than intemperance, and the greatest care 
should be used in this regard to shield the Company from bad risks. No appli- 
cation should be recommended unless the applicant is of strictly sober, 
temperate and correct habits. If he be what is generally termed ' ' a high liver," 
or "social drinker," or if the use of intoxicating liquors has become habitual, 
although he may never have been intoxicated, yet the Company cannot regard 
such a party as a safe risk, and will not knowingly issue a Policy in such a case. 
Nor should offence be taken at this by any one, for life insurance is a business 
to be guarded like other business matters, and must be pursued under the ordi- 
nary well-established grounds of safety, if it is to be made successful. 

6. If the applicant for insurance is a female, the Examiner should not 
only make as thorough personal examination as the circumstances will admit, 
but should possess himself, if necessary, through her usual medical attendant, 
of any and all facts relative to diseases, or symptoms of disease, she may have 
had peculiar to her sex. In all cases where pregnancy exists, the application 
should be declined until after recovery from confinement ; and great care 
should be exercised in recommending females between the ages of forty and 
fifty, or until the " change of life " is fully passed. 

7. If the applicant for insurance is an aged person of sixty years or more, the 
Examiner should direct his attention particularly to the constitutional diseases 
of age, remembering that at this period of life there is an increased tendency 
to urinary diseases, to fatty degenerations, cardiac, and other obstructions from 
undue deposits, and general failure of the vital forces, with paralysis and the 
like. Especial vigilance should be exercised to detect incipient signs of any of 
these, and unless the applicant is an especially good risk, with an unexception- 
able family record, and vigorous physique, the application should be declined. 

8. If the applicant be of excessive weight (or the reverse), or out of the 
usual proportion in any way, as, larger around the waist than chest (a fact 
which may be due to accumulation of fat, or development of muscle, and which 
in one case may depreciate, and in the other improve the risk), full explanations 



CONNECTICUT GENERAL LIFE INSURANCE COMPANY. S$ 

should be furnished. If unusually spare for his height, stoop-shouldered, or 
possessed of any peculiarity, physical or otherwise, which may have a bearing 
on the risk, it should be stated fully. 

9. It is not possible within our limits, nor is it thought necessary, to notice 
specially every point connected with making examinations. If well qualified, 
the necessary inquiries will occur to the Examiner, and if he, in any just degree, 
realizes the vast importance to the Company of his report, and the responsi- 
bility he assumes in his recommendation, we are sure that neither will be given 
without the most careful and thorough investigation. 

The sound common sense of the medical man is especially necessary, and 
the prime qualification of the Examiner. If there is doubt in any case, the 
benefit of the doubt should always be given to the Company. We are not so 
anxious to do business as to be willing to accept any doubtful or uncertain risk. 

10. Whenever there is necessity, or for any reason he prefers, the Exami- 
ner is requested 'to communicate directly with the Home Office. We desire he 
should do so freely, at all times when it seems to him best, and his communi- 
cations will always be regarded as confidential. 

11. If a policy has not been taken in proper time, or has lapsed, and a 
reexamination is ordered by the Company, the Examiner should personally 
examine the party with the same care and minuteness as when first examined, 
so as to be able to make a certificate in the following form : — 

I have made careful personal examination of 

of and hereby certify that he is in sound health, and 

that no change has occurred in his personal or family history or in his personal habits, 
since his former application and examination of 18... 

Except 

[Signed.] M. D. 



CONNECTICUT MUTUAL LIFE INSURANCE 
COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 



Family History. — Where ages, causes of death, etc., are unknown, or very 
uncertain, require the applicant to ascertain them for you, or, if this appears 
impracticable, endeavor at least to establish the general hereditary tendencies 
and longevity of the family, and that deaths were not caused by any trans- 
missible disease, as consumption, insanity, paralysis, apoplexy, or heart disease. 

Personal History and Examination. — Ascertain and state whether his various 
ailments, injuries, etc., have been trivial or severe, and whether they have left 
any injurious effect. To the questions regarding vaccination, rupture, tumors, 
deformity, malformation, and injury, your reply, after careful inspectio7i, is 
desired. 

Special attention is directed to the necessity of a very thorough and critical 
exploration of the chest for the detection of incipient disease. Never be satis- 
fied simply with the absence of abnormal conditions, as rales and murmurs, 
but be equally positive of the presence of the normal. 

The Applicant's Habits regarding the use of alcoholic stimulants, opium, 
and tobacco should be definitely ascertained, and in stating them in your Report 
avoid the use of such words as "moderate," "occasional," and "temperate." 
Where their daily or frequent use is suspected assure yourself that the stomach, 
liver, kidneys, and nervous system are free from any evidence of injury. 

Urinalysis is always required and, for the aid of any who may desire it, 
brief rules are given below. Various tests, aside from those detailed below, 
are considered trustworthy, but the ones mentioned are easily applied and 
sufficiently accurate. If others are used, state in your Report what test was 
employed. 

The Microscope should always be used when, in a case otherwise acceptable, 
there is a suspicion of disease requiring its aid for assurance, as where there is 
a history of calculus, or cystitis. 

It may occasionally occur that the information elicited will be of such a 
character that the Examiner will hesitate to place it upon the Report as fully 
as is desirable. In these cases we invite correspondence with the consulting 
physician at the Home Office, where all such communications are held strictly 
confidential ; and in any case where the applicant requests it, or the Examiner 
deems it advisable, the Report may be sealed in envelopes supplied for that 
purpose before being delivered to the Agent for transmission to us. 

BRIEF RULES FOR URINALYSIS. 

Be sure that the urine is that of the applicant and examine it within 24 hours 
after it is voided. After noting the color, reaction, and specific gravity, fill a 
clean test-tube half full of the clear urine (previously filtered if turbid), and 






SO HOW TO EXAMINE FOR LIFE INSURANCE. 

holding it at an angle of 45 degrees, allow nitric acid to trickle gently down 
its side and form a stratum, under the urine, at the bottom of the tube. If 
carefully done the two fluids will not mingle. Should any hazy or whitish cloud 
be observed at the point where the urine and acid meet, apply heat, and if the 
cloud remains, albumin may be considered present. 

Note. — Urine containing resinous matters, as when a patient is taking turpen- 
tine, balsam copaiva, etc., will sometimes give a whitish-yellow cloudiness, 
similar to albumin, with nitric and hydrochloric acids. The addition of alcohol 
will cause this to disappear at once. 

It is important to hold the test-tube in a proper light in order to distinguish 
slight changes, where only a small amount of albumin is present. The best 
way is that advised by Dr. John Munn, viz. : Place some dark material over 
the lower part of the window, as a background, and draw the shade down to 
it. Now, holding the test-tube a little way from this background, lift the shade 
forward, enough to allow the rays of light to pass through the tube without 
shining into your eyes. In such a light, and against the dark background, 
very slight opacity becomes visible. 

To detect sugar : fill a clean test-tube to the depth of half an inch with 
Fehling's standard test solution and boil it. If it is pure and reliable it will 
remain clear and of a dark blue color. While the clear solution is hot, add 
the urine, a few drops at a time. Sugar will cause a deep yellow or orange 
colored precipitate before the amount of urine added equals the quantity of test 
solution employed. If there is no change, once more heat to boiling and stand 
it one side. When cool, if there is no change sugar may be considered absent. 
Squibb's Fehling's Test Solution is reliable and can be obtained through any 
druggist. 

When the specific gravity is above or below normal, or albumin or sugar 
are present in very small quantity, it will be well to collect the total secretion 
of 24 hours and examine a sample of this mixed urine. 

Table Exhibiting the Healthful Average Relation Between 
Height and Weight. 



height. 


WEIGHT. 


LIMIT. 


Under. 


Over. 


5 ft. 1 in. 
5 ft. 2 in. 
5 ft- 3 in. 
5 ft. 4 in. 
5 ft. 5 in. 
5 ft. 6 in. 

5 ft. 7 in. 
5 ft. 8 in. 
5 ft. 9 in. 
5 ft. 10 in. 

5 ft. 11 in. 

6 ft. 


120 lbs. 
125 lbs. 
130 lbs. 
135 lbs. 
140 lbs. 
143 lbs. 

145 lbs. 
148 lbs. 
155 lbs. 
160 lbs. 
165 lbs. 
170 lbs. 


96 lbs. 
loo lbs. 
104 lbs. 
108 lbs. 
112 lbs. 
114 lbs. 

116 lbs. 
119 lbs. 
124 lbs. 
128 lbs. 
132 lbs. 
136 lbs. 


144 lbs. 
150 lbs. 
156 lbs. 
162 lbs. 
168 lbs. 
172 lbs. 

174 lbs. 
177 lbs. 
186 lbs. 
192 lbs. 
198 lbs. 
204 lbs. 



THE EQUITABLE LIFE ASSURANCE SOCIETY 
OF THE UNITED STATES. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

I. OF THE MEDICAL EXAMINER. 

The Medical Examiners of this Society are officers regularly commissioned 
in the Society's service. They are selected and appointed exclusively by the 
Society's Medical Department through its own channels. Agents have no con- 
cern whatever iti the premises — neither in the procuring of 'appointments, 7ior 
even in the making of original nominations for vaca?it examiner ships, except 
by courtesy. Examiners will, therefore, understand that they hold office from 
the Medical, and not from the Agency Department of the Society, and that 
they are, consequently, responsible to the Medical Department only. Agents 
are not authorized to direct Examiners concerning their duties. 

Examiners are commissioned to hold office during the pleasure of the 
Society's Medical Directors for the time being. After appointment, they are not 
removed except for cause, but they may be subject to retirement after attain- 
ment of the age of sixty-five years. 

Commissions are valid only for the place of residence of the Examiner at 
the time of appointment. Subsequent removal of residence to another locality 
renders a commission void. 

For small settlements, a single Examiner only is commonly appointed, such 
Examiner then having the privilege of all medical examinations for the Society, 
required at his place of residence, no matter by what agent or broker applica- 
tions may be secured. For towns or cities of a considerable size, in addition 
to the ordinary Examiner, one, or, if need be, two alternate or extraordinary 
Examiners are commissioned to serve, in association with the ordinary Exam- 
iner, for cases requiring two medical reports, or for the making of single exami- 
nations when, for any reason, the services of the ordinary Examiner for the 
place may not be available in season. 

Qualification for Medical Examinership is constituted by the possession of 
adequate professional skill and experience, good judgment, integrity, independ- 
ence, respectability and a courteous readiness to respond promptly to calls for 
the making of examinations. This last mentioned item is important for the 
reason that unless candidates for assurance are examined very shortly after the 
making of application, the business may be lost through a subsequent change 
of mind. What is not required of an Examiner (although, of course, gratify- 
ing when willingly done) is either to insure his own life in the Society, or to 
actively influence others so to do. Open disparagement of the Society, how- 
ever, is held to disqualify. 

Compensatio7i for services as Medical Examiner is ordinarily by a fixed fee 
for each examination made and reported, no matter whether the risk be 
approved or condemned. Such examination includes the testing of the urine 

87 



88 HOW TO EXAMINE FOR LIFE INSURANCE. 

for specific gravity, reaction and possible presence of albumin or of sugar. 
Traveling expenses of Medical Examiners are not chargeable to the Society, 
but must be the subject of private arrangement between Examiner and Agent. 

II. OF THE MEDICAL EXAMINATION. 

Although the point is obvious, it is well for completeness' sake to remind the 
Examiner that he should refuse service in any case where an adverse result 
would be of concern to himself. He should, therefore, not consent to examine 
an intimate friend or a near relative, if there be any other competent physician 
available for the case, and should, of course, under no circumstances, act as 
Examiner for a proposed assurance of which he is to be himself, either in 
whole or in part, the beneficiary. Also, it is hardly necessary to add, an 
Examiner should never accept any share of an agent's commission or any 
other consideration of value on a case of his own examining. 

In proceeding to his duty, the Examiner should bear in mind the grave 
responsibility of his office and the peculiar conditions that attend a medical 
examination for life assurance. In the case of an examination of a patient for 
the sake of indications for treatment, one visit can ordinarily be supplemented 
by others, and, in obscure cases, judgment be reserved; but in the examination 
for life assurance a single interview is, commonly, all that is accorded, and yet 
upon the results of the. same an immediate and definite opinion must be ren- 
dered. Furthermore, in the case of an examination as a preliminary for thera- 
peutics, the outcome — a policy of treatment — is one designed at most but for 
temporary continuance, and is one which is at the same time subject to with- 
drawal or variation at will ; but in the case of an examination as a preliminary 
for assurance, the outcome is a policy whose contract must endure for life, and 
that, too, with terms unchanged and unchangeable from issue to maturity. For 
these reasons an examination for life assurance should be punctiliously thor- 
ough, no matter how healthy the subject may appear, and the Examiner's 
recommendation in the case should be rendered only after most careful and 
conscientious consideration. 

The examination should be so conducted as to satisfy in full the require- 
ments of the Society's blank form for the examination-report, and the report 
should be made upon one of such forms. It is the business of the solicitor 
who presents the subject for examination to provide the Examiner with a report 
blank. 

All questions put by the blank should be answered, but the Examiner is not 
expected necessarily to use the phraseology of the blank in making his inqui- 
ries of the candidate. 

Upon the Society's blank form for use in the United States appear the fol- 
lowing practical "Instructions to Medical Examiners," which are here reprinted 
for general information : — 

" Instructions to Medical Examiners. — I. Conduct your examination 
in private, and not in the presence of agents or others ; and insist on being 
accorded the ti77ie and quietness of place necessary for thorough examining. 

" II. Make your report full and precise. Such report has to serve the Medi- 
cal Directors at the Home Office as a basis for a professional judgment on the 
risk. 



THE EQUITABLE LIFE ASSURANCE SOCIETY. 89 

"III. In the matter of the family hi : story, seek always, as regards causes of 
death, to elicit the specific disease, especially where there may be a suspicion of 
consumption. Such suspicion always attaches in case of death ascribed to 
'exposure,' 'general debility,' 'childbirth,' 'change of life,' 'effects of cold,' 
'liver complaint,' 'fever,' etc., so that in such cases the report should, if 
possible, state explicitly that phthisis was or was not an element of the fatal 
illness. 

" IV. In the matter of personal history, ask specifically the questions neces- 
sary to cover the points of inquiry called for by the blank. And do not accept 
for reply any general negative, such as, ' Oh, I have never been sick.' Many 
occurrences bearing on assurability, but which yet do not constitute illness, 
such as an haemoptysis, an otorrhcea, a fistula, or a stricture, are often for- 
gotten by candidates until specifically inquired about. 

"V. In the matter of physical exa?ni?iation, make the same thorough, no 
matter how sound the candidate may appear, nor how well you may know him. 
For the practice of auscultation, in the male subject, the coat and vest should 
be taken off, and the linen shirt rolled up from below out of the way ; and, in 
the female, the waist of the dress and the corsets should be removed. Other 
physical explorations and the necessary disrobing for the same will be at your 
discretion, according to the circumstances of the case. 

"VI. In the matter of the testing of the urine, so apply your tests as to 
detect the presence of even small amounts of albumin or of sugar. For such 
detection of albumin, the common heat-and-nitric-acid test is efficient enough 
if applied in the following manner : First acidify with a drop or two of acetic 
acid, then fill a long test-tube three-quarters full, and, holding the same by the 
bottom, boil the ttpper portion, only, of its contents. Holding the tube now a 
few inches in front of a black background set before a window, compare the 
upper, boiled, stratum of fluid with the lower, unboiled, one, and any patho- 
logically important amount of albumin will be shown by a distinct cloudiness 
of the upper stratum of urine, distinguishable from the cloudiness of precipitated 
phosphates by its persistence after addition of a drop of nitric acid. As regards 
sugar, test for this constituent in all cases, regardless of specific gravity. In the 
beginnings of diabetes, as in temporary glycosuria, the amount of glucose in 
the urine is commonly not enough to run the specific gravity out of bounds. 
Take by preference, furthermore, the urine secreted during active digestion, 
since in the beginnings of both albuminuria and glycosuria the morbid con- 
stituents may be present during digestion while absent in the intervals. 

"VII. In the matter of habitual indulgence i7i alcoholics, report specifically 
what the candidate drinks and how much. Such phrases as 'temperate,' 
' drinks when he wants to,' give no information, and are worthless for the pur- 
pose of the report. In reporting ' over-indulgence,' draw the line — since there 
must be some one fixed standard — at Anstie's limit of a daily allowance equiva- 
lent to one and a half ounces of absolute alcohol. Such allowance will be 
represented in the case of ardent spirits by three ounces ; of sherry or other 
strong wine, by two wineglassfuls ; of claret, champagne, or other light wine, 
by one ' pint ' bottle ; of strong ale or porter, by three tumblerfuls ; and of light ale 
or beer, by four or five tumblerfuls. In cases of excess of any of these amounts, 
therefore, answer carefully the accessory questions required by the blank. 



90 HOW TO EXAMINE FOR LIFE INSURANCE. 

"VIII. In any matter of delicacy affecting the risk, you have the privilege 
of writing, under seal, direct to the Medical Directors, at the Home Office (120 
Broadway, New York).* Such communications are solicited and will be held 
in strict confidence. 

" IX. In forming your opinion of the life as an assurance risk, remember 
that the question is not merely the narrow one of whether or not the candidate 
is, at the moment, healthy and sound, but is the broader subject of his chances 
of living — chances that may be affected as much by abode, occupation, habits 
of life and hereditary tendencies as by present condition of health. A wise 
judgment, therefore, requires the weighing of all the influences now or pros- 
pectively affecting the life. 

" X. If so requested by the candidate, for the purpose of holding private his 
medical history, you are authorized to deliver to the agent your report sealed. 

" XI. In the event of your giving an adverse opinio7i upon a risk, or of your 
declining to examine a candidate because of foreknowledge of his ineligibility, 
you are particularly requested to communicate the fact confidentially to the 
undersigned,* stating name, residence, and occupation of the objectionable 
candidate, date of your unfavorable action and reason for the same." 

Besides the matter of the candidate's physical condition, the subject of the sani- 
tation of his " environment" should receive careful consideration at the hands 
of the Examiner. For now that so many acute diseases are known to be due to 
preventable causes, life assurance companies feel that they have aright to such 
protection from risk of early death from " zymotic " disease as maybe afforded 
by intelligent inquiry into the sanitary condition of a candidate's work and 
living rooms. Of course — desirable though it would be — it is not expected 
that the Examiner will, in every instance, visit and critically inspect both 
the home and the office or workshop of his subject, but it is asked that he will 
make a pointed inquiry into the conditions of the environment, and, if a suspi- 
cion of serious fault of sanitation appear, refuse to report the risk until, in some 
way, the facts in the case can be authoritatively determined. Analogous re- 
search should also, so far as practicable, be made into the matter of the mode 
of life and moral surroundings of the subject, since many a life, without flaw so 
far as physique is concerned, may yet prove a very bad risk, indeed, because of 
moral hazard. 

III. OF THE RATING OF THE RISK. 

Many of the circumstances affecting life assurability are so clear cut in their 
influence that comment is unnecessary, but others either affect assurability vari- 
ously under varying conditions, or are held in various degrees of esteem by 
insurance authorities. The following schedule exhibits the theory and practice 
of the home Medical Directors of the Equitable Society in regard to the more 
prominent of the circumstances of the latter-named categories. It is to be 
understood, however, that while degrees and periods of disqualification are 
ordinarily as stated, such statements do not constitute inviolable rules, but the 
Medical Directors reserve the privilege of recommending at will the acceptance 
or rejection of any given proposal. For convenience of reference, items are 
listed alphabetically by title of subject. 

* Or, in foreign countries, to the Medical Director at the Branch Office. 



THE EQUITABLE LIFE ASSURANCE SOCIETY. 9 1 

Albuminuria. —Persistent albuminuria, whether continuous, cyclical, or irregu- 
larly intermittent, and whether or not accompanied by other derangement of 
the urine, or by derangement of health of the subject, disqualifies during con- 
tinuance, and also for a period after apparent final disappearance, according 
to the individuality of the case. In the event of the finding of a small amount 
of albumin in an otherwise normal urine from an apparently healthy subject 
not past middle life, the Examiner should apply the microscope, and should 
also make a sufficient number of supplementary testings on other occasions to 
establish whether the condition be transient or persistent. 

Amputation. — Amputation of a lower extremity above the knee imposes an 
addition to the premium rate equal to )i per cent, of the amount of the assur- 
ance. Other single amputations are not regarded. Double amputation of either 
set of limbs above the wrist or ankle, respectively, disqualifies. 

Apoplexy. — Any history of a distinct, idiopathic apoplectic seizure apparently 
due to an organic cerebral affection ordinarily disqualifies permanently. 

Asthma. — Asthma manifests itself so variously that cases have to be judged 
on their individual merits. 

Blindness. — Blindness of both eyes imposes an addition to the premium rate 
equal to yi per cent, of the amount of the assurance. Blindness of one eye is 
not regarded. 

Bronchitis, of any grade, disqualifies during continuance. Chronic bron- 
chitis and frequently recurring attacks of acute bronchitis disqualify perma- 
nently. 

Calculus. — Passage of a calculus (whether urinary or biliary) disqualifies for 
a minimum term of five years after occurrence. A frequency of recurrence 
sufficient seemingly to portend a distinct predisposition to the formation of 
calculi (urinary or biliary) disqualifies permanently. 

Cancer, i?i the Subject. — Any history of a cancer of any variety permanently 
disqualifies. 

Cancer, in the Family Record, is not regarded unless there be several cases 
in the immediate family, or an unbroken succession of several in the immediate 
ancestry. Cancers of the uterus, of the mamma and of the skin are regarded 
as of least import in establishing a cachexia possibly transmissible by inheritance. 

Caries, if of any extent, disqualifies during continuance. 

Chancre. — See Syphilis. 

Chancroid disqualifies for a term of six months after initial appearance (this 
to protect against possible errors of diagnosis). 

Colic, Hepatic. — See Calculus. 

Colic, Intestinal. — Frequent recurrence of severe intestinal colic disqualifies 
during the continuance of the habit. 

Consolidation of Lung, if considerable, disqualifies. 

Consumption, in the Subject. — Any history of undoubted phthisis pulmonalis 
in the past, even if recovery has been complete, ordinarily disqualifies. 

Consumption, in the Family Record. — It is regarded as fairly demonstrated, 
first, that consumption is, proportionately , as common at one age as at another ; 
secondly, that as between thin and stout subjects, the thin are very much more 
obnoxious to the disease than the stout ; thirdly, that among family stocks, 
special family susceptibility, of varying degrees, may often be traced ; and, 



92 HOW TO EXAMINE FOR LIFE INSURANCE. 

fourthly, that the immediate determining cause of a given case of phthisis may 
often be direct contagion. With these points in mind, it is held that the bearing 
of a consumptive family record on a given risk cannot be gauged by the con- 
siderations alone of present age of the candidate, number of consumptive 
dead in the family, and ages at death of the several decedents. Hence, in 
the practice of the Equitable Society, no set rules are followed for postponement 
or rejection of candidates with a family record of phthisis, but each case is 
judged on its individual merits, with, in general, the attaching of more weight 
to the consideration of the present physique of the candidate, than to that of his 
present age, or than to that of the number of consumptive relatives dead. In 
view of the many-sidedness of the subject, therefore, Examiners are earnestly 
requested to inquire as fully as possible into the probable causation of all cases 
of death from phthisis encountered in a family record, and to record the results 
in the examination reports. 

Curvature of Spine. — Anteroposterior curvature of the spine either disquali- 
fies permanently, or limits to endowment assurance, terminating at an age not 
exceeding fifty years. 

Lateral curvature of the spine, unless quite considerable, is not regarded. 

Deafness. — Total or practically total deafness imposes an addition to the 
premium rate equal to ]/ z per cent, of the amount of the assurance. Loss of 
hearing in one ear only is not regarded. 

Delirium Treme7is. — Any history of delirium tremens, whether recent or in 
the far past, ordinarily disqualifies permanently. 

Emphysema of Lungs, if considerable, ordinarily disqualifies permanently. 

Epilepsy. — Confirmed epilepsy, of course, disqualifies permanently. A 
history of recurring epileptiform fits in the past disqualifies variously, according 
to case. 

Family History. — See under the several titles of the diseases concerned. 

Fistula-in-a?io disqualifies during continuance, and for the term of one year 
after cure. 

Gout. — Confirmed gouty diathesis either disqualifies permanently or limits 
to short endowment, according to case. 

Hemorrhage from the Respiratory Tract (excepting, of course, an epistaxis) 
ordinarily disqualifies for a minimum term of ten years after occurrence. 
Recurring attacks disqualify for long periods or permanently, according to case. 
(The Examiner should remember the common practice of the medical adviser 
in reassuring sufferers from this affection at the time of their seizure. Hence 
insurance candidates are almost certain, in all innocence, to describe their 
past attack or attacks as trivial, and to fix the site of the hemorrhage in the 
"throat.") 

Heart Lesions. — Any chronic organic affection of the heart — enlargement, 
permanent dilatation, valvular insufficiency or stenosis, probable fatty degene- 
ration or pericardial adhesion — disqualifies, without exception, permanently. 

Heart Murmurs. — All undoubtedly abnormal heart murmurs, whether ad- 
judged of organic or of functional causation, disqualify during continuance. 

Hemiplegia. — See Paralysis. 

Hernia. — Irreducible hernia disqualifies permanently. Reducible hernia, 
whether of one or of both sides, imposes only a special clause in the policy 



THE EQUITABLE LIFE ASSURANCE SOCIETY. 93 

contract, reading as follows : " Provided always that death, in consequence of 
not wearing a truss, is not assured against." 

Humpback. — Sec Curvature of Spine* 

Intemperance. — Present habit, of course, disqualifies. Past habit disqualifies 
for a term after discontinuance, according to case — and the later the reformation 
the longer the term. Any commonly recurring excess over Anstie's limit of 
daily indulgence (see ante) is regarded, so far as concerns the purport of this 
paragraph, as "intemperance." 

Necrosis. — Any considerable necrosis disqualifies during continuance. 

Occupation. — Occupations involving special risk from accident impose addi- 
tions to the premium rate, ranging from % per cent, to 2 per cent, of the amount 
of the assurance, according to case. Prominent examples of such occupations 
are mining, seafaring, and "railroading''' (locomotive engineer, railroad con- 
ductor, train-hand, switchman, coupler of cars), etc. 

Occupations involving the sale of alcoholic beverages of any kind, where the 
business is strictly wholesale, impose an addition to the premium rate equal to 
Yz per cent, of the amount of the assurance. 

The following occupations disqualify absolutely : selling or personally dis- 
pensing alcoholic beverages at retail; gambling, pool selling and "book 
making." 

Otorrhoea. — Simple purulent otorrhcea, if intermittent and trivial only, is not 
regarded; but if considerable, or, even when slight, if persistent, it imposes an 
addition to the premium rate equal to y z per cent, of the amount of the 
assurance. 

Persistent otorrhcea, where the secretion is greenish in color or offensive in 
odor, or where there is a history of the occasional discharge of blood, of* gritty 
matter or of spiculse of bone, disqualifies during continuance and for a minimum 
term of one year after apparent final disappearance. In all cases of otorrhcea, 
therefore, the Examiner should make the necessary investigation to cover the 
foregoing points and should recite the result in his report. 

Paralysis, Facial. — Ordinary so-called "Bell's paralysis," of undoubted 
peripheral causation, is not regarded. 

Paralysis, Hemiplegia. — Any history of an undoubted idiopathic hemiplegic 
seizure ordinarily disqualifies permanently. 

Paralysis, Paraplegic , disqualifies during continuance, and otherwise accord- 
ing to case. 

Pleurisy, recurring, disqualifies according to case. 

Pleuritic Adhesions, if permanent and considerable, ordinarily disqualify 
permanently. 

Pregnancy is not regarded unless there be special reasons for apprehension, 
individual to the case. 

Prostate. — Confirmed enlargement of the prostate disqualifies permanently. 

Pulse. — Confirmed over-rapidity (over ninety beats per minute), tinder- 
rapidity (under fifty beats per minute) of the pulse rate, or systematic irregularity 
of the pulse, ordinarily disqualifies during continuance. Simple i7itermittence 
of the pulse in subjects not past middle life, if not excessive and if constitutional 
to the individual, is not regarded. 

Race. — Negroes, whether of pure or of mixed blood, who reside outside of the 



94 



HOW TO EXAMINE FOR LIFE INSURANCE. 



tropics, are charged an addition to the premium rate equal to yi per cent, of 
the amount of the assurance. 

Rheumatism. — An attack of acute articular rheumatism disqualifies for one 
year after beginning of convalescence. Recurring attacks may disqualify per- 
manently. Chronic rheumatism disqualifies variously according to case. 

Sarcoma disqualifies like cancer (which see). 

Sex. — Women are charged an addition to the premium rate equal to y z per 
cent, of the amount of the assurance, until after the attainment of the age of 
forty-eight years. 

Stone in the Bladder disqualifies during presence. 

Stricture of the Urethra (organic) ordinarily disqualifies during continu- 
ance. 

Sugar in the Urine, if associated with the rational signs of diabetes, ordinarily 
disqualifies permanently. If not so associated, but if yet the sugar be fairly 
abundant in amount, the condition disqualifies during continuance, and for a 
term after apparent final disappearance, according to the case. A trace only 
of sugar found in a urine of normal specific gravity from a seemingly healthy 
subject, and demonstrated by an appropriately timed series of testings to be 
temporarily present only, and that, too, during the high tide of digestion of a 
meal including starch or sugar, is not regarded. 

Sunstroke disqualifies for a term, according to the case. Recurring attacks 
may disqualify permanently. 

Syphilis. — Primary syphilis, not followed by constitutional symptoms, dis- 
qualifies for a term of six months after initial appearance. 

Secondary syphilis disqualifies, ordinarily, during continuance, and for a 
minimum term of three years after disappearance of the last manifestation. 

Any history of tertiary or inherited syphilis ordinarily disqualifies perma- 
nently. 

Tapeworm disqualifies during presence of the parasite, and for a term of 
six months after alleged discharge of the entire worm. 

Ulcer. — Any considerable ulcer disqualifies during continuance. 

Vaccination, Lack of. — Declaration of lack of even the customary vaccina- 
tion of infancy, imposes a special clause in the policy contract, reading as 
follows: "Provided always that death by or in consequence of the smallpox 
is not a risk assumed by this Society unless after successful vaccination." 

Weight. — Pronounced disproportion of weight in either direction disqualifies 
variously, according to case. Excessive disproportion may disqualify abso- 
lutely. Following is the commonly accepted standard table of proportionate 
weights : — 



Height. 

5 ft. 


American Standard. 
Average Weight. 

. . . 115 


Height. 

5 ft. 8 in., 






Am er 
Ave 


ican Standard, 
rage Weight. 

I48 


5 ft. I in., . . . 


. . 120 




5 ft- 9 in., 








• 155 


5 ft. 2 in., . . . 


. . 125 




5 ft. 10 in., 








160 


5 ft- 3 in -» • • • 
5 ft. 4 in., . . . 

5 ft- 5 in- • • • 
5 ft. 6 in., . . . 


. . 13° 
. • 135 
. . 140 
. . 143 




5 ft. 11 in., 

6 ft. • 

6 ft. 1 in., 
6 ft. 2 in., 








I6 5 
170 

175 
l8o 


5 ft- 7 in-, . . . 


. . 145 















THE EQUITABLE LIFE ASSURANCE SOCIETY. 



95 



For the effect on assurability of factors other than the above, the Examiner 
must be his own judge, and a point that merits mention in this connection is 
that of the general impression which the subject makes upon the professional 
eye of the Examiner, quite apart from the results of technical examination. If 
such impression be unfavorable, even though no definite physical flaw appear, 
it is the duty of the Examiner to respect his instinct and to decline the risk. 
Rejection in such cases is all the more imperative for the reason that, by the 
very nature of the consideration in question, the same is one that can only 
appear to the eye of the Examiner, who has the subject before him in the flesh 
— the Medical Director at the Company's office, with but a pen-and-ink exhibit 
by which to judge the risk, being, by that very circumstance, debarred from all 
possibility of forming an intelligent, independent opinion in the premises. 



Mortality Table. Assured Lives. 

(American Table of Mortality adopted by the State of New York as the standard for the valuation of 

policies.) 



S a H 


Number 


Deaths 


1 
. 

§ w a 


NUMBFR 


Dfaths 


1 . 

g w a 


Number 


Deaths 


m O 


Surviving at 


in Each 


O £ O 


Surviving at 


in Each 


oS a 


Surviving at 


in Each 


CU 


Each Age. 


Year. 


Ph 


Each Age. 


Year. 


0, 


Each Age. 


Year. 


IO 


100,000 


749 


40 


78,106 


765 


70 


38.569 


2,391 


II 


99,251 


746 


41 


77,341 


774 


71 


36,178 


2,448 


12 


98,505 


743 


42 


76,567 


785 


72 


33,730 


2,487 


13 


97,762 


740 


43 


75,782 


797 


73 


3**243 


2,505 


14 


97,022 


737 


44 


74,985 


812 


74 


3Z,738 


2,501 


15 


96,285 


735 


45 


74,173 


828 


75 


26,237 


2,476 


16 


95,550 


732 


46 


73,345 


848 


76 


23,761 


2,431 


17 


94,818 


729 


47 


72,497 


870 


77 


21,330 


2,369 


18 


94,089 


727 


48 


71,627 


896 


78 


18.961 


2,291 


19 


93,362 


725 


49 


7o,73i 


927 


79 


16,670 


2,196 


20 


92,637 


723 


50 


69,804 


962 


80 


14,474 


2,091 


21 


91,914 


722 


51 


68,842 


1,001 


81 


12,383 


1,964 


22 


91,192 


721 


52 


67,841 


1,044 


82 


10,419 


I,8l6 


23 


90,471 


720 


53 


66,797 


1,091 


^3 


8,603 


1,648 


24 


89,751 


719 


54 


65,706 


i,H3 


84 


6,955 


1,470 


25 


89,032 


718 


55 


64,563 


1,199 


85 


5,485 


1,292 


26 


88,314 


718 


56 


63,364 


1,260 


86 


4,i93 


1,114 


27 


87,596 


718 


57 


62,104 


1,325 


S7 


3,o79 


933 


28 


86,878 


718 


58 


60,779 


i,394 


88 


2,146 


744 


29 


86,160 


719 


59 


59,385 


1,468 


89 


1,402 


555 


30 


85,441 


720 


60 


57,917 


i,546 


90 


847 


385 


3i 


84,721 


721 


61 


56,37i 


1,628 


9i 


462 


246 


32 


84,000 


723 


62 


54,743 


i,7i3 


92 


216 


137 


33 


83,277 


726 


63 


. 53,030 


1,800 


93 


79 


58 


34 


82,551 


729 


64 


5^230 


1,889 


94 


21 


18 


35 


8l,822 


732 


65 


49,341 


1,980 


95 


3 


3 


36 


81,090 


737 


66 


47,36i 


2,070 








37 


8o,353 


742 


67 


45,291 


2,158 








38 


79,6ll 


749 


68 


43J33 


2,243 








39 


78.862 


756 


69 


40,890 


2,321 









96 



HOW TO EXAMINE FOR LIFE INSURANCE. 
"Expectation" Table. Assured Lives. 

(Constructed from the foregoing Mortality Table.) 





EXPECTATION. 




EXPECTATION. 




EXPECTATION. 


YEARS OLD. 




YEARS OLD. 




■ YEARS OLD. 






Years. 




Years. 




Years. 


IO 


48.7 


40 


28.2 


! 

70 


8.5 


II 


48.I 


41 


27.5 


71 


8.0 


12 


47-4 


42 


26.7 


72 


7.6 


13 


46.8 


43 


26.0 


73 


71 


14 


46.2 


44 


25-3 


74 


6.7 


15 


45-5 


45 


24.5 


75 


6.3 


16 


44.9 


46 


23.8 


76 


5-9 


17 


44-2 


47 


23.1 


77 


5-5 


18 


43-5 


48 


22.4 


78 


5-i 


19 


42.9 


49 


21.6 


79 


4.8 


20 


42.2 


5o 


20.9 


80 


4-4 


21 


4i-5 


51 


20.2 


81 


4.1 


22 


40.9 


52 


19-5 


82 


31 


23 


40.2 


53 


18.8 


83 


3-4 


24 


39-5 


54 


18. 1 


84 


3-1 


25 


38.S 


55 


17.4 


85 


2.8 


26 


38.1 


56 


16.7 


86 


2.5 


27 


37-4 


57 


16.1 


87 


2.2 


28 


36-7 


58 


15 4 


88 


1.9 


29 


36.0 


59 


14-7 


89 


i-7 


30 


35-3 


60 


14.1 


90 


1.4 


31 


34-6 


61 


13-5 


9 1 


1.2 


32 


33-9 


62 


12.9 


92 


1.0 


33 


33-2 


63 


12.3 


83 


0.8 


34 


32.5 


64 


11.7 


94 


0.6 


35 


3i.8 


65 


11. 1 


95 


o.5 


36 


3ii 


66 


10.5 






37 


3°-4 


67 


10.0 






38 


29.6 


68 


9-5 






39 


28.9 


69 


9.0 







Long and careful observations have shown that though the life of any given individual 
is proverbially uncertain, yet, if a large number of persons in ordinary circumstances 
at a given age be taken, there is a law, fixed and uniform, determining within very narrow 
limits the average number of years of life remaining to them. For example, if we take 
10,000 persons at the age of 29 years, the sum of their ages at death will amount to about 
650,000 years, showing that, on an average, each person now 29 years old will live very 
nearly 36 years longer. This mean after-lifetime is called the expectation of life at the 
assured age, that is, the number of years which one at that age may expect probably to 
live, though many will die sooner, and even 72 out of 10,000 during the first year. 



THE HOME LIFE INSURANCE COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

That you may understand our views of the interesting and important 
relation which you sustain to this Company — of the manner of entering 
upon and conducting your examinations, and of the main points of inquiry 
submitted to you in our blank forms — permit us, very respectfully, to request 
your careful attention to the following suggestions and instructions. In com- 
municating them to you we would not be understood as attempting to teach 
you in matters pertaining to your profession, but simply to remind you of many 
points which, while they may be familiar to the educated physician, may never 
have claimed his attention in connection with their bearing upon Life Insurance, 
and as affecting the chances of longevity in individual cases. 

THE CHARACTER OF THE RELATION. 

The relation which a Medical Examiner sustains to a Life Insurance Com- 
pany is one of a strictly confidential character. His appointment is direct from 
the Home Office. He occupies his position entirely independent of agents and 
solicitors, and should therefore always feel that he is peculiarly the guardian 
of the interests of the Company, and bound by every consideration of personal 
and professional honor to discharge his very important and responsible duties 
with the utmost fidelity, and with an eye single to those interests. 

Our Agents are instructed that all examinations must be made by our regu- 
larly appointed physicians, when practicable ; and if soliciting in a new field, 
they are to report to us at once the name of some regularly educated physician 
of skill and good character to act for us ; but in no case should he ever solicit 
a physician for insurance by holding out the inducement of appointing him as 
medical examiner. The fee allowed by the Company for each examination is 
from $2 to $3, and is paid whether the applicant is received or rejected ; and 
when urinary analysis is necessary a corresponding amount in addition. 

In all cases where the application is for over $5000, we require such a 
chemical and microscopical analysis as would reveal, if present, albumin, sugar, 
casts, or blood or pus corpuscles. 

THE RELATIVE POSITION OF APPLICANT AND EXAMINER. 

It is obvious that in conducting examinations of parties for Life Assurance, 
the relations existing between the applicant and the Examiner are wholly 
different from those which the physician sustains to his patient, and that the 
conduct of the patient will differ accordingly. It should be borne in mind, 
therefore, that while in one case the patient is ready and eager to communicate 
each unfavorable symptom which he imagines to exist, in the other he is tempted 
to withhold everything that may convey an unfavorable impression. It be- 
comes necessary, therefore, that the Examiner shall be on the alert to seek 
out any indications of hidden disease, and any constitutional or acquired ten- 
dency or predisposition thereto. 

7 97 



98 HOW TO EXAMINE FOR LIFE INSURANCE. 

FIRST, HAVE THE PAPERS ALL BEFORE YOU. 

Before an applicant is examined, the application, together with the certificate 
of his family physician and personal friend, should be completed and placed 
in your hands. It is important, in all cases, to have the certificate of the family 
medical attendant, whether he has ever had occasion to prescribe for the appli- 
cant or not, and we desire you to require it, unless you are satisfied that it can- 
not be obtained, in which case, please state the fact in your report. 

READ ALL THE ANSWERS CAREFULLY, AND REVIEW THEM WITH THE . 

APPLICANT. 

When the papers are handed to you, please read with care all the answers 
of the applicant and of his friend and physician ; and when he presents him- 
self for examination, read over to him the questions and his answers distinctly, 
so that he may again consider whether he has given full and explicit answers 
on all the points referred to. It will often occur, by this course, that the Ex- 
aminer will obtain information from the applicant which he has withheld in 
his application, and which will aid materially in arriving at a correct conclu- 
sion in the case. 

A SOUND LIFE THE ONLY STANDARD. 

Conduct your examinations with the fact constantly in mind that our rates 
for assurance are predicated on a sound life ; that there is no average standard, 
the simple question being, Is the party, so far as you can possibly discover, 
free from disease or any personal, hereditary, or acquired predisposition to 
disease ? If after the most thorough examination, your mind is in doubt on 
this question, you will of course advise that we decline the risk. 

REPORT FULLY AND DEFINITELY. 

Referring to the questions contained in the form for your certificate, we beg 
that your answers to each shall be as definite as possible as to all the points 
embraced. 

GENERAL CONDITION. 

The first thing to which the attention of the Examiner is attracted, before 
proceeding to the detail of a personal examination, is the condition of the party, 
both as to personal health and social condition. An impression at first sight 
favorable to the party or otherwise is involuntary ; but however strong this may 
be, it should serve only to prompt the Examiner to follow out these indications 
until he discovers the causes which so vividly impart their character to the 
general appearance. The occupation and personal habits, in their varied form 
and connection, and the influence of family predisposition, will therefore be 
first considered. 

OCCUPATION. 

The studious man of nervous temperament discovers himself by the pale 
face, the intellectual expression, and the quick comprehension of any subject 
which maybe suggested. In those of this class, whose imaginations are active, 
we look for an overtaxed brain which, in its extravagance, may lead to mental 
disease. Others of the same class, occupied in pursuits where the judgment is 
brought into action, suffer from sluggishness of the system, and torpor of the 
entire digestive apparatus. The comniercial man, accustomed to tax all his 



THE HOME LIFE INSURANCE COMPANY. 99 

powers to accomplish a certain object, exhibits often the effect of mental ten- 
sion in an unmistakable aspect ; anxiety is depicted on the face ; you see clearly 
that he is a dyspeptic. In some, their appearance indicates that their ability 
to digest and assimilate food is nearly gone. Clerks, Book-keepers, Watch- 
makers, Engravers, Shoemakers, and all whose occupation leads them to press 
the chest in a constrained posture, will show the effects on the general form of 
the body, in the measurement of the chest, and in the features and expression 
of the face. 

Bakers, Cooks, Glass Workers, Working Engineers, Founders, Black- 
smiths, suffer from deteriorated air, and the alternation of cold and heat. Such 
persons show the effects of their modes of life in fatal diseases of the pulmonary 
organs, and of the hepatic system. Of all occupations, those persons exposed 
to vegetable and mineral emanations exhibit the greatest amount of mortality; 
next are those who work in places where dust abounds (as in flour mills), Stone- 
cutters, Cullers, workers with thresliing machi?ies, etc., the effect of whose 
occupation is to aggravate greatly any constitutional tendency to consumption, 
and to induce bronchial disease. Workers in lead or arsenious preparations, 
Paper Slainers, Lucifer Match Makers, all workers in ?netallic melting, are apt 
to be short-lived. Plumbers and Painters, subject as they are to partial paralysis 
and colic, and other effects of lead poisoning, are to be taken with extreme 
caution, if at all. Pyrotechnists should be deemed ineligible for Life Insurance. 

COMPLEXION. 

This term is used to denote the color of the face, as pale, dark, ruddy, sallow, 
etc. The intelligent Examiner will note the complexion very carefully, and 
draw important conclusions from it. If the family history of the party examined 
shows that they have not been long-lived, and that some of them have died of 
hepatic disease, and should he present the well-known sallow complexion of 
even a slight chronic affection of the liver, the Examiner will hesitate ; or a 
decidedly pale appearance of the face may be a sufficient reason for withhold- 
ing approval. This extreme paleness often marks the existence of chronic dis- 
eases of various kinds. A very ruddy or florid complexion indicates plethora, 
and where diseases of an apoplectic character have been in the family, suspi- 
cion should be excited by this appearance. A dusky, or leaden, or livid, hue 
should lead to a careful examination of the thoracic organs, and especially of 
the heart, as indicating imperfect aeration of the blood, or obstruction to the 
venous circulation. A bright pink color sometimes exists in connection with 
valvular disease. 

A scrofulous physiognomy exhibits the face slightly bloated ; skin delicate, 
whitish, transparent, somewhat pink, or of a rosy tint; eyes blue, pupils large ; 
upper lip thick ; nose slightly swelled, red and shining ; hair light. 

GAIT. 

A tardy or laborious gait indicates either debility of the muscles, bones, or 
joints. A staggering gait occurs from vertigo. A tottering gait is often the 
result of habit, but in some instances it marks the sequel of disease of the hip- 
joint. A bowed gait (walking with the body bent) is a sign of muscular 
debility, or affection of the spine. A stiff gait (when the joints of the lower 



IOO HOW TO EXAMINE FOR LIFE INSURANCE. 

extremities are but little moved) may be the consequence of tumors in the 
inguinal regions or perineum, of psoas abscess, hernia, or disease of the genito- 
urinary organs, or of the rectum. 

MUSCLES — BONES. 

The general excessive but uniform development of the muscular system 
shows a preponderance of the vascular system, and such persons are in general 
good risks. Imperfectly developed muscles, with bones small and slender, 
show a tendency to nervous debility. The affections to be apprehended in 
such persons are those of the brain and diseases of the form known as asthenic ; 
slim bones are also indicative of phthisis. Firm muscles indicate good health, 
and a state of nutrition proportionate to the activity of the muscular system. 
The absence of fat is not inconsistent with a healthy and vigorous constitution. 

HABITS. 

Intemperance in the use of alcoholic drinks is a fruitful source of disease. 
Persons who now are, or ever have been, addicted to habits of intemperance, 
are in all cases to be declined. The experienced Examiner will easily detect 
the signs of an habitual drinker of intoxicating liquors. The condition of the 
nervous system will reveal the fact ; the offensive or ether-like odor of the 
breath ; furred or tremulous tongue ; the eyes, etc. But it is not so easy to 
detect the fact when the party has but just commenced the destructive habit, 
and therefore extreme vigilance on this point is required. 

In this connection we would call your attention to the greatly increased 
drinking of beer, the tendency in very many cases being to its excessive use, 
which, when once become a fixed habit, sensualizes and degrades the mind as- 
well as the body, and is a potent factor in reducing the average of life. When 
you have reason to believe, either from inquiry or an unusual plethora of the 
applicant, that he is a large consumer of it, the risk should be declined. 

Tobacco. — Allied to the use of intoxicating drinks is the inordinate use of 
tobacco. The effects of the habit are to be considered relatively to the consti- 
tutional peculiarity of the individual. The oil of tobacco, as is well known, is 
a violent poison. If its use can be entirely abandoned, the general health would 
be vastly promoted ; but this is too much to hope for ; we must, therefore, con- 
sider its use in connection with its supposed effects. These are frequently an 
inordinate disturbance of the nervous system, producing a permanently rapid, 
often intermittent, pulse, occasional palpitation of the heart, loss of appetite, and 
emaciation. Where these symptoms are found to exist, the life should not be 
recommended until the habit has been abandoned, and the functions of the 
system have been restored to healthy action. 

Opium. — The opium eater must, of course, in all cases, be declined. 

SIZE. 

Ascertain and state the exact weight and height, the circumference of the 
chest at inspiration and expiration, and the circumference at the abdomen. 

The table annexed, of weights, as to height, will be your general guide, any 
marked deviation from which should attract attention, and call for a rigid 
examination as to its causes ; the simple fact of such variation, however, is not 



THE HOME LIFE INSURANCE COMPANY. IOI 

to be regarded as conclusive ground for rejection. In cases where the weight 
is excessive, we are to inquire of what it consists ; if of large bones and muscles, 
with corresponding strength, it is evidence of large vitality ; but if it consists of 
great deposits of fat, with a large abdomen, the conclusion must be unfavor- 
able to the life. In cases where the increase of weight is above the standard, 
but where the increase has been gradual, the risk is to be regarded more favor- 
ably than in those in which the same condition has been rapidly obtained. 
Intemperance, either in eating or drinking, or both, and the absence of regular 
habits of exercise, are the usual causes of such rapid increase in size. Loss of 
weight occurring rapidly will indicate the presence of some form of pulmonary 
disease, or of some affection of the kidneys ; if the same process be slow, it 
points to chronic diseases ; in either case the life must not be recommended. 
If a person whose weight is much above the standard is at times subject to 
drowsiness or other signs of cerebral congestion, or to the existence of chronic 
eruptions or ulcers, or if there is anything in the history of the family indicating 
a disposition to apoplexy or palsy, the risk must of course be declined. 

In order to come to a just conclusion in such cases, it is indispensable to 
ascertain the antecedent personal history of the applicant in these respects. 

MEASUREMENTS. 

The chest should be measured with a marked tape, over the nipples, while 
in a state of expiration, and also when inflated. The difference is, in the 
average, two inches. Should the expansion be not more than half an inch, the 
party ought at least be temporarily rejected, until, by habitual inflation, the ability 
to expand the chest is decidedly improved. This can be done with advantage to 
the general health, but is only to be required of the party when there is no positive 
evidence of affection of the vital organs, because if such evidence exists, no 
further inquiry is pertinent in the case. The measurement must be taken under 
the vest. If there be any pain on expanding the chest, the part where it exists 
must be noted, and subjected to the most careful scrutiny by auscultation 
and percussion. A well-formed chest appears, on a casual inspection, to be 
symmetrical, but it is not so. The right side is found to be larger than the left, 
and there is naturally a little more fullness on the left side beneath the left 
clavicle than beneath the right, owing to the left lung rising higher than the 
right. With these exceptions, the healthy chest appears uniformly rounded, 
and free from bony projections. The form known as "pigeon-breasted'" and 
"chicken-breasted'" is not in itself a ground for rejection if the general capacity 
is maintained, and the uniformity is complete. Distortions of shape, as the 
flattening of some part, particularly in the subclavian region, should excite a 
suspicion of tubercle. Enlargement about the middle of the chest marks 
dilatation of the pulmonary cells, or enlargement of the heart. Pleurisy will 
leave ligamentous attachments, and thus flatten the chest on one side. Where 
this flattening is marked in extent, it may become a serious source of future 
disease. 

The abdomen, especially if unduly prominent, should also be measured, as 
when taken in connection with the height and weight, it will form an important 
element in determining the insurability of the applicant. 



T02 HOW TO EXAMINE FOR LIFE INSURANCE. 

VACCINATION, 

Now so universally adopted, is, of course, an essential pre-requisite to life 
insurance ; it should be ascertained, as far as possible, if it has been satisfac- 
torily performed. 

The evidence of the protecting power of vaccination, in any given case, is 
the appearance of the cicatrix — the circular form with remains of the vesicular 
pits, cannot be mistaken, and, when found, is sufficient. As to whether the 
effect of vaccination is not destroyed by time, there are different opinions. 
The probability is that if it is properly performed, and has taken properly, its 
protection will be permanent. In justification of the opposite opinion, how- 
ever, it should be remarked that different persons have more or less suscepti- 
bility to both the vaccine disease and smallpox, and in many this susceptibility 
may not have been extinguished by one vaccination. The modified smallpox 
may, therefore, appear in some during the prevalence of an epidemic. To 
guard against this, it is always well at such times to have the vaccination per- 
formed the second time, that whatever susceptibility to the disease still remains, 
may be destroyed ; and in any case where doubt exists, a revaccination should 
be insisted on. 

RESPIRATORY ORGANS. 

The Vibration of the Voice is felt by applying the hands to the chest while 
the party examined is requested to count audibly. 

This will often lead to the discovery of pulmonary disease, and when a 
difference between the two lungs is marked, the facts will come more clearly to 
light by auscultation and percussion. 

The difference in vocal vibration is important, in proportion to the extent of 
surface over which the difference is observed. 

Auscultation, either by the ear alone or with the assistance of the stetho- 
scope, or by striking the chest with the fingers, will reveal the quality of the 
respiration. In the normal condition the inspiration exceeds the expiration 
in duration and audibility. Inspiration increases uniformly in intensity, until 
the middle of its duration, when it becomes weaker, until it is imperceptible, 
when the sound changes to that of expiration, without any pause. The normal 
length of the expiratory sound is about one-third that of the inspiration. Any 
deviation from this is a sign of disease — the greater the duration of the expiration 
the more significant of wrong. The departures from healthy respiration neces- 
sary to be carefully noted are, the varied intensity in different parts of the 
chest, the cessation of vesicular murmur — blowing or bronchial respiration — 
the crepitating sounds, the amphoric bruit, the ascending and descending sound 
of fluctuation and cavernous' ronchi. The sounds of the voice important to 
the examiner are bronchophony, segophony, and pectoriloquy. 

Peraission is one branch of auscultation, although custom has confined the 
latter term to the listening of sound by the ear applied to the chest. Percussion 
elicits sound by striking on the walls of the chest. The lungs being spongy in 
their structure, containing a quantity of air, they yield, when struck, a sound 
somewhat hollow, but much less so than if the parts were empty. The more 
air there is within, the more hollow it will sound ; hence the difference in sound 
on inspiration and expiration. The chest imparts a clear sound when there is 
more air, and less clear as the quantity is diminished. The thickness of the 



THE HOME LIFE INSURANCE COMPANY. IO3 

walls of the chest affect the sounds also — it is much more dull if the parts are 
covered with muscles or fat The lungs are in contact closely, on both sides, 
in the upper and middle part. They extend, on the right side, to the sixth rib 
in front ; on the left side to the seventh ; and at the centre to the fifth. The 
mass of the liver on the right side produces a dull sound below the level of the 
sixth rib. The lungs are, indeed, in close contact with the wall of the chest 
in every part, with the exception of a small part to the left of the sternum 
occupied by the heart ; here the chest yields a dull sound. Wherever the 
substance of the lung is thin, the sound of percussion is modified by the viscus 
lying immediately behind it, as in the region of the liver. Percussion can con- 
vey no positive information of the real state of the organs which convey air, 
where the diseased portions are thinly scattered, as in miliary tubercles ; yet, 
taken in connection with other signs, maybe of importance. This remark will 
be understood when it is borne in mind that the sound may be more or less 
obscure when corresponding parts of the chest are compared and varieties, if 
any, noticed, according to the parts percussed. The departures from health to 
be noticed on percussion are dullness and the cracked sound referred to in 
treatises on physiological examinations, the latter denoting pulmonary cavities 
lying near the surface of the lungs. . 

THE HEART. 

Vibrations from the action of the heart may be ascertained by placing the 
hand over this organ, at the point corresponding to its apex, at the sternum, 
and at the epigastrium. We are thus enabled to judge of the strength with 
which the heart acts. If the hand is raised over a limited space with some 
force the natural inference is that the heart is strong ; if no such effect is per- 
ceptible, it is weak. A large heart and a small chest, with a general disposition 
to emaciation, do not furnish a good subject for insurance. A very strong 
impulse must be a cause of rejection, allowance being made, however, for the 
effect of temporary excitement in persons of a nervous temperament ; whether 
the disturbance is from the latter cause must be determined by prescribing to 
the party a little delay and rest. If necessary, two or three examinations should 
be made at different times, so that the Examiner may fully satisfy himself on 
this very important point. Impulse felt over a very extensive surface usually 
indicates hypertrophy or other disease sufficient to cause rejection. 

Any abnormal sound of the heart conveyed to the ear in auscultation, even 
such as are ascribed to ansemia, must, while it lasts at least, be regarded as an 
absolute disqualification. 

Percussion reveals that the heart is in contact with the chest from twenty 
to twenty-four lines in all directions. The heart, where it is not in contact with 
the parietes, extends about one and a half or two inches to the left, and is cov- 
ered with a thin layer of pulmonary substance. The distance from the clavicle 
is three to three and a half inches. Whenever there is eccentric hypertrophy, 
there is an obscure sound over the heart, and, if it is considerable, the dullness 
is very extensive. When the muscular structure is dense, as in concentric 
hypertrophy, the dullness is not so marked, but the strong impulse denotes its 
condition. The marked dullness of greater or less extent, and the permanent 
increased impulse, are the points demanding the most careful notice. 



104 H0W T0 EXAMINE FOR LIFE INSURANCE. 

DISEASES OF THE HEART 

are among those which have prevailed in families. Successive generations 
have had enlargements of this organ, or have been affected with aneurisms. 
When a parent has died of these diseases, it is necessary to examine the appli- 
cant with more than ordinary care. Advancing age in diseases of the heart 
tends to aid in their development rather than to better the predisposition, as in 
the case of phthisis. 

Palpitation. — Increased action of the heart from whatever cause is the foun- 
dation of this symptom. The slightest mental emotion, fatigue, anything that 
increases the movement of the organ ; sometimes palpitations are transient or 
momentary ; at others persistent, strong and tumultuous. Every opportunity 
should be afforded to tranquillize the nervous system on the appearance of this 
symptom. Easy and composed conversation during the examination ; a second 
interview, referring the candidate to some occurrence which may have hap- 
pened a short time before ; a recumbent posture, etc. All this on the supposi- 
tion that it arises from a temporary disturbance of the nervous system, and for 
the purpose of testing thoroughly the correctness of that theory or the reverse. 
If the party is subject to these affections, it is necessary to keep in mind the 
causes which often induce them — as eccentric hypertrophy, ossifications, valvu- 
lar disease, adhesion of the heart to the pericardium, polypi, obstructions in the 
aorta, and affections which disturb the lesser circulation. 

The Large Blood Vessels. — The blood vessels are liable to diseases at their 
origin, and to aneurism and ossifications. The sound indicating the existence 
of an aneurism is much like the bellows sound. 

ASTHMA. 

Asthma is a frequent symptom of some organic disease affecting the heart, 
larger vessels, or lungs, and it is always to be referred to one of these organs 
for its origin, unless it can be satisfactorily ascertained that it is purely spas- 
modic or attributable to the effect of indigestion or the inhalation of the dust of 
hay, ipecacuanha, or other irritant cause in the atmosphere. One cannot be 
considered as cured, even of spasmodic asthma, unless a long period of immu- 
nity has existed since an attack. It is, moreover, not to be forgotten that persist- 
ent or frequently repeated paroxysms of asthma may be a cause as well as a 
consequence of disease of the heart. All such cases, therefore, should be 
received with great caution. 

COUGH. 

No person should be received who labors under a cough. The only ques- 
tion that has ever arisen is in regard to those who are subject to cough, but who 
at the time of examination are free from it. There ought, however, to be no 
doubt in these cases ; all such persons must be declined until sufficient time 
has elapsed (several months or a year) to prove conclusively that the party has 
ceased to be subject to this affection. 

SPITTING OF BLOOD. 

This is a subject of great interest to the medical examiner, for in the greater 
number of instances it indicates a disposition to phthisis. Simple bleeding 
from the respiratory organs does not itself mark a serious affection of the lungs, 



THE HOME LIFE INSURANCE COMPANY. IO5 

because the appearance of the blood in the mouth does not always denote that 
it has come from the pulmonary tissue. The source of the blood may be, first, 
from the mucous membrane of the air passages, or from the pharynx, a simple 
exudation ; second, from rupture of a blood vessel ; and, lastly, from tubercles 
in the lungs. Bleeding from congestion of the mucous membrane of the bron- 
chial tubes is often transient, and frequently gives permanent relief; its lightest 
form, that of simple exudation, need not be a cause for rejection; sufficient 
time must be allowed to elapse to ascertain, together with an examination of 
the chest, that it is of this nature. Rupture of a blood vessel from violent 
straining need not be a reason for declining the party, allowing, as in the case 
just mentioned, a long time to elapse to prove conclusively that it is but local 
and temporary, unconnected with constitutional affection. If either of these 
should be followed by a cough or occasional difficulty of respiration, the party 
must of course be declined. It is needless to mention that such persons require 
a much more careful examination as to the physical condition of the lungs, or 
that their personal history, and that of their family, must be entirely unexcep- 
tionable as regards diseases of the respiratory system. Parties sometimes state 
that they have had spitting of blood, when upon careful inquiry it appears evi- 
dent it has come from bleeding gums, from the back part of the nose, or from 
a scratching cough, simply removing a small portion of the mucous membrane 
of the throat; all such cases are of no importance; but it is very iinportant 
not lightly or carelessly to assign them to this category. When blood is the 
production of tubercles it frequently makes its appearance in streaks in the 
mucus expectorated in ordinary coughs ; this and regular haemoptysis are the 
serious affections to be guarded against, and, where any symptom of these 
exist, the case must of course be declined. 

INCIPIENT PHTHISIS. 

The suggestions already made with respect to the organs of respiration will 
indicate sufficiently the signs of phthisis in its incipiency. It will not be amiss, 
however, to note here some of its rational symptoms. They are so obscure at 
the beginning that it may be useful to allude particularly to them here. Regu- 
lar phthisis usually begins with a short dry cough, so slight often as to become 
habitual, before it attracts attention. It is often without any other symptoms 
than mere lassitude, with a peculiar clearness of the complexion and a remark- 
able pearly lustre of the eye, and will continue to progress a long time before 
there are other symptoms positively indicating disease of the lungs. The 
breathing will become hurried and easily increased by exercise ; when the 
disease advances the cough will gradually become more severe, especially at 
night, with straitness and oppression in the chest, and expectoration of frothy 
mucus, sometimes tinged with blood. It is unnecessary to say that when any 
of the symptoms of this terrible disease are found to exist, the party is ineligi- 
ble for life insurance. 

FAMILY HISTORY. 

In connection with this subject, it is to be observed that the greatest caution 
is demanded when several of the family of the applicant are said to have died 
in childbed. Experienced examiners have long since come to regard these 
statements as either made ignorantly or with a design to mislead, for the num- 



106 HOW TO EXAMINE FOR LIFE INSURANCE. 

ber of deaths reported from this cause in applications for life insurance greatly 
exceed those within the experience of any physician, and which are reported in 
any reliable way. Every physician of experience knows how in cases of phthisis 
the fatal period is postponed by the progress of pregnancy, and how rapidly it 
approaches after confinement. On a careful inquiry it will usually be found 
that the mother or sister has been feeble for months ; has had a cough, and has 
died in a short time after the birth of the child. Whenever, therefore, there 
has been a death in the family from consumption, it is fair to presume that the 
death in childbed was from the same cause, unless there are clearly estab- 
lished facts to rebut this presumption. 

Pulmonary disease transmitted through the family demands very careful con- 
sideration. The inquiries addressed by the Company to the applicant, relating 
to the family history, are, of course, designed to elicit the facts as to the exist- 
ence of any such hereditary taint. Diseases of family origin, termed hereditary, 
are, more properly speaking, predispositions. Hence, the actual development 
of disease requires some cooperating circumstances, and it is not in every 
instance where the parent has had disease of the pulmonary system that the 
applicant should be pronounced uninsurable. Consumption does not always 
descend from the parent to the child ; but, if either parent has been so affected, 
and the offspring exhibits a slender form or has a narrow, badly formed chest, 
or an habitually rapid pulse, the predisposition is evidently so strong that some 
slight exposure or irregularity of living, or a constrained occupation in a close 
atmosphere, will almost surely develop the disease. Where both parents have 
died with pulmonary consumption, the party ought to wait till he has reached 
the period of life at which he is likely to be exempt. The danger is supposed 
to be measurably passed at say 45 years. When the party has reached that 
age free from any indications of the disease, he may be considered as beyond 
the probability of being exposed from the family predisposition. 

In cases of collateral branches of the family, as brothers and sisters, the 
applicant must have passed the ages at which they died, and be himself free 
from any suspicion or tendency to the disease. While much must be left to 
the sound judgment of the Examiner, taking carefully into consideration all the 
facts bearing on the probability that the party is subject to such family predis- 
position, he should always incline to reject applicants in whose immediate 
family two cases of consumption have occurred. 

BRONCHITIS, 

acute or chronic, disqualifies the party. It is not unusual for the applicant 
to state that the party is perfectly well, with the exception of " a slight cold." 
All such cases must be postponed until the bronchial affection has passed 
away. If chronic bronchitis exists, of course the decision is to be deferred till 
the fact of cure is completely established. In all these cases there is great 
occasion for the exercise of sound judgment. The Examiner will consider the 
family and personal history of the party, the nature and frequency of the 
attacks, personal appearance, bodily condition, occupation, etc. Millers, black- 
smiths, and all workers in trades from which dust ejnanates, public speakers, 
etc., are in great danger from any tendency to bronchial difficulties. Affections 
of the pharyngeal mucous membrane are not to be confounded with those of 



THE HOME LIFE INSURANCE COMPANY. IO7 

the tracheal and bronchial mucous membrane. The trouble in the upper part 
of the oesophagus is often transient, arising from slight dyspepsia. 

ARTERIAL PULSATION. 

The pulse of the adult male may be stated at 75 beats in a minute, and of 
the adult female 85, when in a sitting posture. The difference has been known 
to be as much as 26 beats between standing and sitting, but instances occur 
where no difference exists. The average difference is about 10 between sitting 
and lying. A very great difference is found in the frequency of the pulse at 
different times of the day ; it is much more frequent in the morning, and de- 
creases as the day advances. The pulse is often much accelerated after violent 
exercise, active mental exertion, and after eating and drinking freely ; of course, 
the Examiner will consider these accidental effects. One of the most annoy- 
ing circumstances attending an examination is the nervous excitement of the 
party, especially when the Examiner commences his investigations ; the pulse 
beats violently and the heart thumps immoderately. The sounds are often of 
such unusual character as to lead to the suspicion of cardiac disease ; the 
quickness of breathing will, however, generally convince the Examiner that 
the whole train of symptoms is owing to mere nervous excitement ; a brief sea- 
son of rest, with a quiet, composed and cheerful manner on the part of the 
Examiner, will generally reassure the party. A very good mode is to examine 
the pulse at the commencement, request the patient to be seated, divert his 
attention for a few minutes from the matter in hand by entering into conversa- 
tion on other subjects. He will soon feel either that the dreaded examination 
is over, or that there is no cause for excitement. The pulse will be found to 
have diminished in frequency, and the heart will beat naturally again. 

The beat of the pulse at the wrist has occasionally been the first intimation 
of cardiac disease, for when there is any amount of nervous disturbance it is 
not easily quieted ; it does not readily yield to the usual effects of a recumbent 
posture. The sharp, tense thrill of the artery will remain after all attempts to 
quiet the nervous commotion have failed. The feeble pulse of a hypertrophied 
heart will, with the restored calm, sink into its customary diminished power. 
The pulse, when standing, should not beat more than 90 times in a. minute. If 
it is more frequent at the beginning of the examination, the party should be 
induced to keep entirely quiet, in a recumbent posture, for a considerable 
time ; if, with this treatment, it is not reduced to 90 or below, the case must be 
postponed for a day or two, and other like careful examinations be made. If, 
then, the rate is not reduced to or below 90, the party must be declined. 

A very frequent pulse is in most cases an indication of some organic affec- 
tion, usually of the heart or lungs. 

When the pulse is below 50, it should be regarded as indicating cerebral 
disease or congestion of the medulla oblongata, or hepatic disease, and, of 
course, the risk must be declined. 

The decidedly irregular pulse should lead the Examiner to decline to recom- 
mend the life. There is, however, a kind of uniformly irregular pulse — the 
irregularity consisting in a trifling departure from the rhythm of the heart, and 
occurring as uniformly as if it represented one cog of a wheel of less size than 



108 HOW TO EXAMINE FOR LIFE INSURANCE. 

its fellows. This (if the peculiarity has existed so long as to be fairly deemed 
constitutional) is not a cause for rejection. 

It is always best when the pulsations at the wrist exhibit any departure, even 
temporary, from a strictly healthy condition, to consider it as an indication of 
cardiac derangement, and to hold the case under advisement until the Exami- 
ner is fully satisfied that no such derangement exists. 

NERVOUS SYSTEM. 

The Brain. — Insanity, or any appearance of mental derangement, at any 
time or in any degree, disqualifies for life insurance. 

Insanity in the family, in any branch of it, whether lineal or collateral, must 
be carefully considered. One case will not establish the fact of a family pre- 
disposition, but two certainly will, for our purpose. An attempt is frequently 
made to explain the exciting causes in a given case or cases, with a view to 
show that the party ought not to be declined on account of family insanity. 
One case is traced to religious excitement, another to sexual causes, another to 
intemperance, etc. It is obvious, however, that in all these cases the predispo- 
sition existed in the brain, and needed but some exciting cause to produce the 
development of morbid action. 

Apoplexy and Paralysis. — Any attack of this kind of course disqualifies. 
If both of the parents of the party have died from either of these, the applica- 
tion should be declined. If others of the family than the parents have died 
from these causes, a close investigation should be made as to the condition, 
form of the body, habits of life, and every other circumstance in the case, with 
reference to any probable predisposition of the party thereto. 

Rheumatism. — A very common affection, of peculiar interest to the Exami- 
ner, from its connection with the heart, is rheumatism. When a party states 
that he has had this disease, it will be necessary to inquire very particularly as 
to the nature, severity, duration and frequency of the attacks. A party subject 
to rheumatism must not be recommended, especially if it appears to be a family 
disease, even though there be no evidence of cardiac affection, as the proba- 
bility is that sooner or later this will be developed. Of the two, muscular and 
articular, the latter description is most likely to produce disease of the heart. 

Gout is a most dangerous affection, and is usually regarded as a cause for 
rejection. It is preceded by dyspeptic symptoms and attacks at adult age, 
while rheumatism occurs at any age. Gout attacks the smaller joints, and does 
not usually shift its seat, except by metastasis to a vital part; hence its great 
danger. 

Epilepsy. — This affection, occurring after childhood, must, of course, demand 
the rejection of the party, even if there has been but one attack, or should the 
party have what has been deemed such an attack, though its precise nature is 
left in some degree of doubt. If the parent has been thus afflicted, it is safest 
to decline the child. 

DIGESTIVE SYSTEM AND APPENDAGES. 

Dyspepsia is one of the most common affections, and so long as it indicates 
no other functional loss of the power of digestion, it is not of very serious im- 



THE HOME LIFE INSURANCE COMPANY. IO9 

portance. If, however, there is much emaciation and great debility, or an 
appearance indicating inflammation or some organic lesion, the Examiner will, 
of course, decline the risk. 

Diseases of the Liver. — If it appears that the party has been subject to occa- 
sional attacks of jaundice, or other diseases of a bilious nature, the Examiner 
will not only scrutinize the condition of the system with great care, but will also 
inquire into the causes of death of the members of the family, and their relative 
ages at death to that of the party, as these diseases are among those that are 
traceable to a family predisposition. 

Diarrhoea. — Chronic diarrhoea, and constant tendency to looseness of the 
bowels, often indicate the existence of organic trouble of some kind, especially 
tuberculosis, and therefore such a case should be declined. 

Colic, when produced by indigestion, flatulence, or other transient causes, 
is of no importance ; but the form known as bilious colic is of a different and 
very serious nature. One attack of this kind may be accidental, and is not 
sufficient to warrant the decision that the party is subject to the disease, but 
two attacks will justify this presumption, and the party must be declined. 
When it appears in the application that the party has had one or more attacks 
of colic, it is important that the Examiner shall carefully investigate the facts, 
with a view to decide as to its nature. 

Dysentery, especially after a severe attack, is very liable to recur the next 
year or later ; hence, careful inquiry should be made when the attack has been 
recent, and the case declined if anything indicates the probability of a recur- 
rence. 

Hernia need not render the party ineligible, provided it is properly secured 
by a truss, and the occupation of the individual is such as not to endanger 
its protrusion by excessive straining. It is always proper to examine what is 
described as hernia, for it sometimes proves to be a testicle that still remains 
above the scrotum. In other cases, it is so connected with enlarged veins of 
the scrotum that the wearing of a truss aggravates the danger. In all cases 
the report of the Examiner should describe the extent and character of the 
rupture, and the probable effect of the truss. 

Hernia in the female is, for various reasons, in all cases, a good ground for 
rejection. 

Fistula, if still existing, should reject; and if cured should lead to more 
careful inquiry into the state of the lungs ; for this disease is not infrequently 
associated with tubercle, and when cured usually hastens death from that 
cause. 

GENITOURINARY SYSTEM. 

The consideration of the affections incident to the female, where the genera- 
tive organs are the subject of inquiry, are of much greater importance than in 
the male. There are two periods in the life of a female that ought particularly 
to be regarded as of special interest to the general health — that of puberty, and 
that when the menses are about to cease. If these are passed without any 
diminution of health, the best evidence is afforded of the safety of the risk. 

There is a long intermediate period during which there are derangements 
which must be regarded as rendering the life unassurable. Irregular returns 
and dysmenorrhcea must cause rejection. Frequent miscarriages, if they do 



IIO HOW TO EXAMINE FOR LIFE INSURANCE. 

not indicate natural feebleness of constitution, must tend to impair the health, 
and such cases should be declined, unless there is abundant evidence that the 
danger is passed, and that no serious detriment to the constitution has been 
sustained. If there has been from any cause, even after a healthy labor, severe 
uterine hemorrhage, the application must not be entertained. There is so great 
unwillingness to impart any information on these subjects that the slightest 
unfavorable indications must lead to the inference that much more is concealed, 
and that the risk should be declined. It is deemed best always to decline a female 
during the period of her first pregnancy, and until she has fairly recovered her 
health and strength. 

A contracted pelvis is a fatal objection, of course. Inquiry should be made 
as to history of labors, whether instrumental or not, etc. 

Urinary Diseases, involving any structural change, or even any consider- 
able functional derangement of these organs, should of course reject. Into this 
category comes Bright's disease, diabetes, calculous affections, chronic cystitis, 
enlargement of the prostate gland, and stricture of the urethra. Persons who 
are subject to retention of urine or catarrh of the bladder are not fit subjects 
for insurance. If albuminuria is suspected, the urine should be tested, and in 
some of the other affections a microscopical examination may be desirable. A 
puffy condition of the eyelids, or impaired vision not ascribable to other causes, 
should lead to the suspicion of albuminuria, as either of these may be the only 
symptoms present, even when the disease has already made considerable prog- 
ress, and in all cases where the application is for $5000 or over, apply the test. 

Syphilis. — If there are any symptoms of secondary syphilis, the risk must 
not be advised. 

Injuries and Deformities. — Nothing, of course, need be said of injuries 
which manifestly lessen the prospect of life. There are many, however, that 
indirectly interfere with the full exercise of healthy functional power, in respect 
to which it may be doubted whether they actually impair the expectation of the 
individual. Of the first class are amputations, or other surgical operations'? - 
the cure of disease. These, too, frequently operate only as temporary relief, 
and the disease soon develops itself afresh in some other part, and therefore it 
is always the dictate of prudence to decline to recommend such a case, how- 
ever complete the cure may seem to be. Amputation for injuries need not 
always be a ground of rejection ; great caution must, however, be observed in 
regard to this class of cases. If a large limb has been removed, it is to be con- 
sidered that unless the digestive powers are much impaired, a larger quantity 
of blood will be supplied than the body requires, and plethora, with its conse- 
quences, is very apt to ensue. The Examiner must weigh well all the circum- 
stances in connection with the condition and peculiar circumstances of the 
party, and sufficient time should always elapse after the operation for the devel- 
opment of any change that the constitution may experience. Any injury requir- 
ing the use of crutches will disqualify a person for assurance till the power of 
locomotion is restored or replaced. The toss of an arm, particularly if above the 
elbow joint, is a very dangerous mutilation, because it renders the person 
unable to help himself in danger. 

Blindness and deafness are positive objections, and, if total, disqualify, of 
course. 



THE HOME LIFE INSURANCE COMPANY. Ill 

The deformity of a hunchback, if occasioned by disease, is a cause for rejec- 
tion ; if the result of an injury, it depends on the extent and seat of the injury 
whether the risk should be advised. Angular curvatures (so-called) of the 
spine are frequently attributed to falls, and no doubt this is often the exciting 
cause. But it is to be considered, in this connection, whether the same acci- 
dent would have led to the same result in a perfectly sound constitution. Care- 
ful scrutiny, in most of these cases, will elicit evidence of a scrofulous taint, 
and, unless this is manifestly absent, the case should be declined, even though 
the present health of the party may be good and no morbid process actually 
going on in the spinal column. This applies to the disease whether occurring 
in the lumbar, thoracic or cervical portions of the spine. 

The state of the respiration and other points will be carefully noted, and 
the Examiner will arrive at his conclusion from a very careful survey of the 
whole case, always bearing in mind that any departure from the undiseased 
shape of any part of the chest interferes with a vital operation. 

Deformity of the pelvis has been already referred to as influencing the 
prospects of life in a woman about to be a mother ; in the male it can be of no 
importance unless the urinary organs or the intestines are influenced by it. 

TUMORS AND SWELLINGS 

existing in any part of the body should be carefully scrutinized, and, if not 
unquestionably of a benign character, or if liable to interfere with the func- 
tions of any important organ, are a sufficient ground for rejecting the case. 

REGISTER. 

You will be furnished by us with a suitable book in which to register your 
examinations, and in which, we hope, you will enter all the particulars relative 
to every case that you examine. 

REPORT. 

If for any reason it seems desirable, you can detach your report from the 
application and transmit it direct to the office, with any remarks that you may 
deem it proper to make, and it will in that case be treated as a co7ifidential 
communication. Please be particular to answer all the questions in the form 
for your report categorically. We shall, of course, understa?id that your con- 
clusion expresses only the conviction of your own mind. 

In conclusion, permit us to beg that you will remember, in the discharge of 
your honorable and highly responsible duties, how important it is to the widows 
and orphans, who are the chief parties in interest in a Life Insurance Com- 
pany, that you shall conduct every examination with the best skill and judg- 
ment that you can command. If each Examiner fails to do this in but a single 
instance, and as a consequence we are by each of our Examiners led to assure 
one unsound life, the aggregate would so diminish the average vitality of our 
membership as seriously to injure the institution. 

We earnestly desire to regard our medical advisers as permanent and confi- 
dential officers and friends of the Company, with whom we can communicate 
freely, and on whom we can rely to consult our interests by every means in 
their power. We shall, therefore, always be happy to hear from you on any 
subject of personal or official interest. 



112 



HOW TO EXAMINE FOR LIFE INSURANCE. 

Table of Expectancy of Life. 





EXPECTA- 




EXPECTA- 




EXPECTA- 




EXPECTA- 


AGE. 




AGE. 




AGE. 




AGE. 






TION. 




TION. 




TION. 




TION. 


15 


44.96 


33 


32-30 


51 


I9.50 


69 


9.OO 


16 


44.27 


34 


31-58 


52 


18.82 


70 


8-54 


17 


43-58 


35 


30.87 


53 


I8.l6 


71 


8.IO 


18 


42.88 


30 


30.I5 


54 


I7-50 


72 


7.67 


19 


42.IO 


37 


29.44 


55 


16.86 


73 


7.26 


20 


4I.49 


38 


28.72 , 


56 


l6.22 


74 


6.86 


21 


4O.79 


39 


28.OO 


57 


15-59 


75 


6.48 


22 


4O.O9 


40 


27.28 


58 


14.97 


76 


6.11 


23 


39-39 


4i 


26.56 


59 


14-37 


77 


5-76 


24 


38.68 


42 


25.84 


60 


13-77 


78 


5-42 


25 


37-98 


43 


25.12 


61 


13.18 


79 


5-°9 


26 


37-^7 


44 


24.4O 


62 


12.61 


80 


4.78 


27 


36.56 


45 


23.69 


6s 


12.05 


81 


4.48 


28 


35-86 


46 


22.97 


64 


11.51 


82 


4.18 


29 


35-15 


47 


22.27 


65 


10.97 


83 


3-90 


30 


34-43 


48 


2I.56 


66 


10.46 


84 


3-63 


31 


33-72 


49 


2O.87 


67 


9.96 


85 


3-36 


32 


33-oi 


5o 


20.I8 


68 


9-47 







Table of Height and Weight. 



HEIGHT. 


MINIMUM 
WEIGHT. 


MAXIMUM 
WEIGHT. 


HEIGHT. 


MINIMUM 
WEIGHT. 


MAXIMUM 
WEIGHT. 


Feet. Inches. 


fl>s. 


a s . 


Feet. Inches. 


fts. 


fts. 


5 


IOO 


150 


5 8 


122 


200 


5 1 

5 2 


I05 
I08 


i55 

160 


5 9 
5 10 


125 
128 


2IO 
220 


5 3 
5 4 
5 5 
5 6 


no 

112 

115 
Il8 


163 
165 
170 
180 


5 " 
6 

6 1 
6 2 


I30 
135 
I40 

145 


230 
24O 

245 
250 


5 7 


I20 


190 









JOHN HANCOCK MUTUAL LIFE INSURANCE 
COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

The Medical Examiners of this Company are selected in all cases by and 
hold their office under the Medical Department, and independently of Agents. 
By the terms of your appointment, you will see that the Company depends 
upon you to protect its interests at all points in the selection of lives, and 
desires the fullest information which may in any way affect the risk, in the 
case of every applicant. A report upon every case examined by you is 
required, whether the result of your investigation be favorable or otherwise. 
All special communications regarding applicants, or upon other matters relating 
to your position, which you desire to make privately, may be addressed to the 
Medical Department at the Home Office. Remuneration for services in every 
case is assured to you by the Company. 

There are three elements of great importance in determining the character 
of a risk in Life Insurance, viz.: the personal history, the family record, and 
the immediate condition of the applicant. It is with reference to these divisions 
that the blank is formed which is to guide you in making your examinations 
(see form of this Company). The blank is in all instances to be filled by your- 
self throughout. 

The following directions are intended to call attention to some points con- 
nected with the performance of your duties which are of essential importance, 
but which, nevertheless, do not universally receive their proper degree of 
consideration : — 

Weight. — If excessive, whether due to disproportionate amount of fat or 
muscle ; the relation of present to past standard in reference to sudden cor- 
pulency or progressive loss ; whether other members of the family are or were 
of heavy weight. 

Occupation. — Its nature, whether sedentary, active, exposed to dampness, 
dust, etc. ; its effect upon the health of applicant. 

General State of Health. — Capacity to bear fatigue; whether business is ever 
interrupted by illness ; present condition compared with that of former periods 
of life, etc. 

The Examiner will direct his inquiries in connection with the list of diseases 
especially to the following point : — 

Apoplexy. — Whether disposed to or ever threatened with symptoms of. 

Asthma. — The nature, frequency and duration of attacks ; whether increas- 
ing or diminishing in severity ; whether influenced by residence, controlled by 
treatment, etc. 

Coughs, Prolonged. — Their nature and duration. 

Disease of the Brain. — Any symptoms of functional disturbance ; " rush of 
blood to the head;" impairment of intellect; numbness of limbs; loss of 
muscular sense, etc. 

8 us 



114 HOW TO EXAMINE FOR LIFE INSURANCE. 

Disease of the Heart. — Besides dropsy and palpitation, symptoms mentioned 
below, inquiry should be made with regard to pain in the cardiac region and 
left upper extremity ; disability to ascend stairs or heights ; difficulty or short- 
ness of breathing; fainting; the presence of aretes senilis in old persons, etc. 

Disease of the Lungs. — The nature and duration of any previous affection, 
and completeness of recovery ; disposition to take cold; affections of throat; 
catarrh ; difficulty of breathing ; nature of cough and expectoration ; the exist- 
ence of night sweats, etc. 

Disease of the Liver. — The occurrence of jaundice, and of what duration; 
pain in region of liver and right shoulder ; condition of digestive system, etc. 

Disease of Bladder a7id Kidneys. — In connection with the possibility of any 
affection of the urinary organs, inquiry should be made as to the appearance 
and quantity of urine passed ; pain in the back ; swelling of the feet or ankles, 
and puffiness of the eyelids ; difficulty in breathing ; state of vision, etc. 
Should reason for suspecting the existence of any such affection be discovered, 
a thorough examination of the applicant's urine should be made and the results 
reported. A mere chemical examination is not sufficient to determine the 
existence of some forms of Bright's disease, for instance, in which there is no 
albuminuria, and of which the detection of casts of the renal tubuli by the 
microscope furnishes the only evidence. 

Uriiiary Analysis. — Whenever the specimen passed by the applicant is 
cloudy, it should be invariably filtered before the analysis is made. If the 
specific gravity is found to be over 1030 or below 1012, a second specimen 
should be subsequently analyzed. 

Dizziness. — Its frequency, and the conditions which induce it, especially 
with reference to a tendency to apoplexy. 

Dropsy, including oedema, anasarca, and ascites. Its character. When 
present, even at a distant period of the applicant's history, especial attention 
should be directed to the condition of the heart, kidneys, and liver. 

Diarrhosa. — If chronic, of how long standing ; nature of stools ; how far 
amenable to diet or remedies ; whether increasing or diminishing in severity ; 
its effect upon the system ; whether associated with chronic dysentery (next on 
the list), etc. 

Dyspepsia, including all functional disturbances of digestion. Its character, 
if severe or of long standing ; how far a symptom of other affections, such as 
an organic disease of the stomach, of consumption, of which it forms one of 
the most important and constant premonitory signs, etc. 

Erysipelas. — Parts affected, and frequency of occurrence. 

Fistula. — Its anatomical seat, history, and present condition as determined 
by personal inspection ; is there cough or tendency to consumption ? 

Fits. — If epilepsy has existed at any period of applicant's life, ascertain, if 
possible, its cause, the severity, frequency and duration of attacks ; their effect 
upon the system ; the period which has elapsed since its disappearance, and 
whether treatment for the disease has been continued since that date. 

Gravel. — Its nature to be ascertained from attending physician, or if existing 
at time of examination, by analysis of urine. 

Headache. — Its character, and the causes which produce it, if possible. 

Insanity. — If existing at any past period, its cause, character, and duration 



JOHN HANCOCK MUTUAL LIFE INSURANCE COMPANY. 115 

should be accurately ascertained from the physician then in attendance. The 
mental condition at all times subsequently should be carefully investigated, as 
well as the question of family tendency to the disease. 

Fain in the Back. — A very important symptom in connection with renal 
disease, and if persistent, requiring urinary analysis. 

Paralysis. — Its seat, duration, and character: connection with impairment 
of special senses or intellectual faculties ; effect upon health, etc. 

Palpitation. — Nature and frequency of attacks ; circumstances which pro- 
duce them ; association with other symptoms of cardiac disease ; with fainting 
or dyspnoea ; habits of applicant in respect to the use of tea, coffee and 
tobacco, etc. 

Piles. — Whether external, internal, bleeding, or ever inflamed. 

Rheumatism. — Whether acute, chronic, or muscular ; frequency and number, 
severity and seat of attacks ; whether ever accompanied by cardiac symptoms. 

Rupticrc. — Its history ; its immediate condition and seat (to be determined 
by inspection), whether reducible, retained in place by truss ; and whether the 
latter is properly adjusted and constantly worn. 

Spine Complaints , injuries or deformities of the spine. Their nature, dura- 
tion, symptoms, amount of deformity produced, and effect upon applicant. 

Spitting of Blood. — The most minute inquiry should be made as to the 
nature and circumstances of the case ; the amount and character of the blood 
raised ; whether expectorated, coughed or vomited ; frequency and number of 
attacks, interval between them, and date of last ; existence of cough and state 
of health at those periods. If referred by applicant to some other source than 
the lungs, the grounds for such statement should be closely investigated. The 
personal and family history of such applicants should receive special attention. 

Syphilis. — Whether there have been secondary or tertiary symptoms. 

Stricture of the Urethra. — This is important, as indicating possible bladder 
complications. 

Varicose Veins. — How extensive ; whether accompanied by ulceration at any 
time ; condition of skin surrounding. 

Serious Illness, etc. — If there has been at any time in applicant's history 
any serious illness not mentioned in the list of diseases,, its influence upon his 
constitution should be ascertained and stated. If he has received any injury, 
the vestiges or effects of which still exist, personal examination should be 
directed to such parts, and a description of it given. 

When did you last consult a doctor, a?id for what ? 

Are you 7iow tender a doctor s care ? If so, for what? 

Many applicants who, for various reasons, will give a negative answer to the 
list of diseases enumerated, will be reminded of some illness by the above 
mentioned questions. 

Habits. — Explicit information regarding the applicant's use of intoxicating 
liquors is required in every case. If he has ever used them to excess, state 
how long and to what extent he was addicted to the habit when he desisted 
from it, and how far he may have been injured by it. 

Family History. — The Medical Examiner cannot be too particular in his 
revision of the statements made by applicants in filling the blanks of these Sec- 
tions. In every instance, the assigned cause of death should be made the 



Il6 HOW TO EXAMINE FOR LIFE INSURANCE. 

subject of inquiry, and especially when there is evidence of the existence of 
any hereditary disease in the family record. In all cases, too, the specific cause 
of death should be ascertained where this is possible, and where such definite 
information cannot be obtained, positive evidence of a negative character may 
be of equal importance so far as relates to consumption,' heart disease, apoplexy, 
etc. In this connection avoid the use of all indefinite terms, such as "general 
debility," "change of life," "exposure," etc. 

Health of Family, etc. — The Medical Examiner will also make special 
inquiry with regard to the health of the surviving members of the family, par- 
ticularly if the previous examination has shown evidence of the presence of 
hereditary affections, and will state the nature of the complaint, if any member 
is not in good health. 

PERSONAL EXAMINATION. 

It is not the purpose of the Company in these instructions to offer a code of 
directions for the conduct of the physical examination of the applicant, for the 
character of the medical gentlemen employed at its various agencies is pre- 
sumed to be such as to ensure a thorough performance of this important part 
of their duties. It is desired that all the questions proposed in the Medical 
Examiner's Certificate should be answered with the fullest details, and that 
particularly, when any deviation from the normal condition of the organs and 
functions therein made the subject of special scrutiny is discovered, its exact 
nature shall be stated. If the personal history of the applicant has shown the 
existence at any time of affections which tend to produce, or are connected 
with structural changes of important organs, such as pleurisy, rheumatism, or 
syphilis, for example, a positive statement as to the occurrence or non-occur- 
rence of such changes should always be given, so that it may be known that 
the examination has been especially directed to these points. It is not always 
practicable to examine the chest without its clothing, but if there is the slightest 
suspicion in your mind, growing out of past diseases, which may have possibly 
left their impressions upon the heart or lungs, or out of the family history, 
you should examine these organs without the interposition of its covering. 
Recognizing the fact that, unintentionally perhaps, important facts may 
be withheld from you, you should use your best judgment in deciding whether 
the answers given to your questions coincide with the appearance of the 
applicant. 

Should it be found that the number of respirations or the rate of the pulse 
per minute exceed the normal standard, and it is apparent that such accelera- 
tion is due to nervous excitement or recent muscular exertion, the rate should be 
recounted after a sufficient time has elapsed to allow the lungs and heart to return 
to their natural action. It may even be necessary to test the pulse upon differ- 
ent days to determine this point. In no case should the respirations be recorded 
above 20, or the pulse above 90, without stating explicitly that such means have 
been resorted to. In counting the pulse, also, it is always desirable to observe 
its rate throughout an entire minute, inasmuch as important irregularities in its 
action might otherwise escape observation. Moreover, should any deviation 
.from the normal condition of the heart or lungs be discovered by auscultation 
or percussion, which maybe due to slight and temporary functional derange- 
ment, such, for instance, as the sounds produced within the chest by a cold, 



JOHN HANCOCK MUTUAL LIFE INSURANCE COMPANY. 11/ 

sufficient interval should always be allowed between their detection and the 
re-examination to establish their true character, and the certificate should never 
be filled until this can be explained beyond a doubt. 

ELIGIBILITY. 

Having thus elicited and recorded all the facts of importance in the case 
which personal examination and an investigation of the history both of the 
applicant and his family can furnish, it remains for the Examiner to consider 
the evidence thus obtained, and to express his opinion whether it justifies an 
acceptance of the risk by the Company. This is often a very difficult matter, 
and in some cases, where the evidence derived from these various sources is 
conflicting, it may be impossible for him to come to a positive conclusion. In 
such cases he should give an exact statement of all the circumstances, and the 
reasons of his inability to come to a decision. The final decision in every case 
rests with the Medical Department at the Home Office. 

It is impossible to lay down fixed rules as to what shall constitute absolute 
causes for rejection. In general, it may be stated that applicants are not safely 
insurable — 

If consumption has prevailed to any marked degree in the family ; if 
apoplexy, or heart disease, have occurred in the parents of an applicant above 
the age of fifty years ; if blood has been raised within ten years ; if there has 
been an unhealed fistula within five years ; if he has been intemperate within 
a recent period ; if the pulse is irregular, or persistently above 90 or below 50 ; 
if the weight is greatly disproportionate to the height ; or if a satisfactorily com- 
plete record of the family history cannot be obtained. 

Reference to the medical attendant is always desirable when any point, con- 
nected with the past history of the applicant or that of his family, has not been 
explained by the personal examination to the complete satisfaction of the 
Examiner. 



LIFE INSURANCE COMPANY OF VIRGINIA. 

SUGGESTIONS TO MEDICAL EXAMINERS OF THE COMPANY. 

Medical Examiners of this Company are respectfully and earnestly requested 
to be careful in the examination of every applicant presented; as only persons 
whose condition promises the fulfillment of the table of expectation are desired 
as risks. 

The history of the family of the applicant, his own past history and present 
condition of health are all to be considered before recommending him as a fit 
subject for insurance. 

As regards family history, it is a well established fact that long-lived parents 
produce long-lived offspring. " Longevity is one of the most persistent of 
inheritable characteristics." 

It is equally as well known, that certain diseases are transmitted from parents 
to children. Hence the known fact of the existence of such diseases in the 
ancestry of an applicant should be well and carefully considered, before advis- 
ing the Company to accept him for insurance. The past history of the appli- 
cant 's health is also to be considered. If he has suffered from chronic cough, 
chronic inflammation of throat, chronic bronchitis, hemorrhage from the lungs, 
neuralgia, rheumatism, gout, tumors, fistula, hernia, frequent attacks of kidney 
or bladder diseases, stricture, chronic inflammation of stomach or bowels, 
secondary syphilis, scrofula, etc., their effect in the impairment of health should 
be considered most carefully, as few who have suffered from such diseases are 
fit for insurance. As regards the present condition of applicant : before an 
examination, he should be in good health. Even if slightly indisposed the 
examination should be postponed. If his habits are bad, such as excessive use 
of intoxicating drinks, or narcotics, or tobacco, he should not be recommended. 
The condition of the respiratory , circulatory, urinary, nervous and digestive 
organs should be examined with care. 

As to the respiratory organs, the voice should be clear, the chest should be 
well formed, expansion good, vocal fremitus felt on application of hands to 
chest, motion of chest should be free, equal and even ; the respiratory murmur 
should be heard clearly, so as to satisfy the Examiner that the lungs are 
normally permeated by the air, and that the larynx, trachea, etc., are in sound 
condition ; there should be no cough, nor pains in chest, nor shortness of 
breath ; in healthy respiration there should be an expansion of not less than 
two inches, and the number of respirations should be to the beat of the pulse 
as i to 4 — that is, about 18 to the minute. 

As to circulatory organs, observe that the action of the heart, its position 
and the space that it occupies are normal, that the impulse, rhythm and both 
sounds, indicate healthy condition of the organ and its valves and covering, 
that the pulse is natural as to strength, rhythm, regularity, and frequency, and 
that aneurism or varicose veins do not exist. 

As to organs of diges.tion, observe that deglutition is easy, that there is no 

II 9 



120 HOW TO EXAMINE FOR LIFE INSURANCE. 

disease of stomach, liver, spleen, or any other of the abdominal viscera, that 
there is no irreducible inguinal hernia, no double hernia, and no femoral hernia, 
no diarrhoea, dysentery, nor excessive dyspepsia. 

As to urinary organs, observe that the bladder, urethra, kidneys, and their 
appendages are in good condition, that there is no acute or chronic inflamma- 
tion of bladder, enlargement of prostate gland, stone nor stricture, that the 
kidneys perform properly their functions, that no bloody urine has existed, that 
the urine is healthy (by tests) if disease of the kidney is suspected.* 

As to nervous system, observe that the senses are healthy, that there are no 
tremors, paralysis nor aberration of intellect, no jerking of muscles, nor epilepsy, 
and that the movements of the body and limbs are free and natural. 

In the examination of females, in addition to the above, ascertain that the 
uterine functions are natural and that the menstrual flux is regular in time and 
healthy in condition, that is to say, that there is no amenorrhcea, dysmenor- 
rhcea, or menorrhagia, also that there is no leucorrhcea, etc., no enlargement 
of ovaries, nor ulcerations, nor cancer of neck of womb. If married, whether 
subject to miscarriage or to difficult labors, and if at the change of life, whether 
there be reason to suspect the existence of any disease which is apt to show 
itself at that period. 

Under no circumstances should an applicant be recommended when any of 
the following conditions exist : — 

(i) When both parents have died of consumption. 

(2) When one parent and a brother or sister have died of consumption. 

(3) Where he has had haemoptysis, or when one parent has died of consump- 
tion and the applicant presents any evidence that he may acquire it. 

(4) When the applicant has had apoplexy, paralysis, epilepsy, loss of one of 
the senses, aberration of intellect, or haemoptysis. 

(5) Where there is intermittence, or irregularity of the pulse, or heart's 
action, unnatural sounds produced by action of heart, habitual cough, difficulty 
of breathing, a pulse over 85 or under 60 in the' minute. 

(6) Chronic dyspepsia with emaciation — too great or too little weight, if 
coming on suddenly, chronic diarrhoea, irreducible hernia or femoral hernia, or 
double hernia. 

(7) Cancer, psoas, or lumbar abscess, rickets, coxalgia, or white swelling of 
any of the joints, old ulcer, scrofula, fistula, spinal disease, caries or necrosis, 
permanent enlargement of spleen, chronic disease of liver, dropsy, diabetes, 
disease of kidney, intemperance and use of narcotics habitually, or excessive 
use of tobacco. In females, hernia, menorrhagia, ulcer or cancer of womb, 
ovarian disease, frequent miscarriages, and difficult labors. 

After having maturely considered these points, although the general result 
may prove favorable, still, if the Examiner have reason to believe that the appli- 
cant, from any cause, will not live the period given in the Expectation Table, he 
should decline to recommend. 

The Medical Examiner is independent of any extraneous influence. " He 
is not bound to try to please the Company, nor the Agent, nor the applicant." 
The only wish that the Company has in regard to him is, that he will be careful 

* In all cases where the application is for over $500, the urine must be tested. 



LIFE INSURANCE COMPANY OF VIRGINIA. 121 

in his examination and base his opinion on the results of it, and that if, after an 
examination, any doubt exist in his mind in regard to the propriety of a recom- 
mendation he will give the Company the benefit of the doubt. Whether he 
advise the applicant's acceptance or not, he is entitled to the fee. 

Should any additional remarks, in regard to the condition of the applicant, 
not called for by questions on the application, be deemed necessary, they 
should be invariably made under the words "additional remarks," contained 
on the face of the application at the right corner of the bottom of the paper. 

In making replies to the questions contained in the application the Examiner 
will please give concise replies, as too much writing is apt to make confusion 
and trouble. All the questions should be answered, and the answers to ques- 
tions 14 and 15 should be given without qualification. In answering number 
12, find out, if possible, the disease which caused the death of parents, brothers 
and sisters. Such information is of great importance ; since the word " un- 
known " conveys no information, and often leads to the suspicion that conceal- 
ment is intended, as it is certainly sometimes. 

An individual in good health should approximate the following weight, 
though the exceptions are very numerous, as it often happens that persons in 
good health weigh less. A rapid diminution of weight or a rapid increase 
should attract attention always and lead to an investigation of its cause. 

A person 5 ft. 2 in. in height should weigh 120 to 125 lbs. 

" 5 " 3 " 

" 5 " 4 " 

" 5 " 5 " 

" 5"6 " " " 

" 5 " 7 " 
5 " 8 " 
it 5 " 9 " " " 

« 5 « 10 " " " 

" 6 " " " 160 " 165 " 



125 " 


126 " 


128 " 


135 " 


136 « 


140 " 


140 " 


144 « 


145 " 


148 " 


148 " 


150 * 


152 " 


155 " 


158" 


160 " 



MARYLAND LIFE INSURANCE COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

It is a well-established fact, that no matter how well the financial and other 
business departments of a life insurance company may be managed, unless the 
risks are carefully selected, it cannot continue to prosper. The stability of a 
life insurance company depends, in fact, mainly upon one point, which must 
be continually borne in mind, namely, that the subjects, in the aggregate, 
should outlive the average of longevity. This excess of longevity can only be 
attained by the Medical Examiners exercising the greatest possible caution in 
the selection of risks among the applicants who are presented to them. We need 
not remind you of the necessity of taking into thoughtful consideration every 
point that has any bearing whatever upon the question, as to the probability of 
the individual living beyond the period assigned to him by the tables — calcu- 
lated by the united experience of life insurance companies. Our duty is not 
only one of great delicacy, but it is often attended with much that is disagree- 
able and painful. We are called upon to act as detectives in testing by search- 
ing questions the history of the subject before us, both as to his physical con- 
dition and his habits, past and present. We are obliged to endeavor to ascer- 
tain accurately what were the physical ailments and imperfections of the 
members of his family, even to two generations back. We have to exercise 
great tact, with unobtrusive gentleness, in treading upon such delicate grounds ; 
at the same time our investigation must be thorough and stringent. In arriving 
at a conclusion, after carefully and deliberately weighing everything connected 
with the application, we must never lose sight of one simple rule — that the 
Company is to have the benefit of all doubtful cases. It is, in fine, far better 
that a subject should be refused insurance than thai the Company should take a 
questionable risk. At the same time no applicant should be refused insurance 
when his condition and record entitle him to it. 

Permit us briefly to call your attention to some especial points in the selec- 
tion of risks which have been impressed upon us by a large experience. In 
the questions put forth by this Company, which have been framed with great 
care, you will notice that the applicant is required, previous to your examina- 
tion, to furnish a statement of his exact age, weight, height, all of which have 
an important bearing upon the nature of the risk. The proportion between 
weight and height ought always to be considered. There are exceptional cases 
where there may be decided variations from the standard, but 20 per cent, is 
generally considered the maximum compatible with health. An adult in stat- 
ure 5 feet 6 ought to weigh over 140 pounds. For every inch above and 
below this height we ought respectively to add or subtract about five pounds. 
More decided variations should always be looked upon with suspicion. We 
would especially call your attention to the question as to whether the applicant 
has recently increased or diminished in weight. If such has been the case, it 
would constitute a much more serious objection to the risk than an habitual 
divergence from the normal standard. 

123 



124 HOW TO EXAMINE FOR LIFE INSURANCE. 

The habits of the individual must be closely scrutinized. If his occupation 
be a sedentary, indoor one, in itself it is unfavorable to longevity. If it involves 
great mental strain or unremitting physical fatigue, it must be carefully con- 
sidered. 

This Company avoids especially accepting risks on persons addicted to the 
habitual use of alcoholic stimulants. Many individuals who never drink to 
excess, take more than they can readily excrete. This habit impairs the nutri- 
tion of all the tissues of the body and leaves traces of degeneration in the 
heart, kidneys and liver, as well as of the minute vessels of the brain. We 
must beg you to bear in mind the importance of a close examination for evi- 
dences of constitutional syphilis, visceral as well as superficial. 

Notwithstanding the care that has been exercised of late years in the selec- 
tion of risks, life insurance companies have suffered from the great mortality 
from diseases of the heart and lungs, and from diseases of the kidneys. 
Modern modes of testing the exact state of these organs, if faithfully applied, 
should prevent this. Physical exploration of the chest, together with the gene- 
ral symptoms, enable the Examiners to detect these diseases in their incipi- 
ency. The family record, which should be thoroughly investigated as far back 
as the grandparents, and should include the uncles and aunts on both sides, 
will enable us to find out whether the applicant has any hereditary vulnerability 
to tuberculosis. His personal history as to his having shown any delicacy of 
the respiratory organs must be diligently inquired into. The occurrence of 
haemoptysis in the very large proportion of cases should oblige us to exclude 
the applicant from the benefit of life insurance. 

Modern vital statistics have shown us that from 10 to 12 per cent, of the 
mortality of persons selected for life insurance die from diseases of the kid- 
neys. There can be no doubt but that in past years many of the deaths 
assigned to other causes were, in fact, from one of the forms of Bright's disease. 
We urgently call your attention to these facts. in order that you may be on the 
lookout for every slight alteration in the composition of the urine. You may 
thus detect these diseases in their incipiency before the subjective symptoms 
betray them. 

This Company has established the following rule for the guidance of its 
Medical Examiners. All applicants shall be required to furnish specimens of 
their urine for examination. The Examiners will apply the tests for albumin 
and take the specific gravity. In case the specific gravity is as high as 1026, 
he will also be required to test for the presence of sugar. These examinations 
of the urine are so simple and so easily applied that the Company expects them 
to be made without extra charge. 

When the amount asked for is $10,000 or over, or if the applicant be over 
fifty years of age, the Company expects, for its protection, a thorough physical, 
chemical, and, when possible, a microscopical analysis. The questions in the 
blank are leading ones. This Company expects you to add others if necessary 
to complete your thorough examination. 

In conclusion, we respectfully call your attention to the final question in your 
examination, and beg that you will answer it only after a thoughtful perusal of 
the answers to all the other questions. 



MASSACHUSETTS MUTUAL LIFE INSURANCE 

COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

The stability of a life insurance company largely depends upon the proper 
selection of the lives which it insures. It is the desire of this Company, there- 
fore, that its Medical Examiners should fully appreciate the fact that to them 
are entrusted duties of the most vital importance. The Company aims to secure 
competent physicians only as its Medical Examiners, and upon their careful 
investigations and untrammeled judgment great reliance is placed. 

The Examiner should always bear in mind that his position is an independent 
one. He receives and holds his appointment from the Home Office, made by 
the Chief Medical Examiner of the Company, after an investigation of his fitness 
for the position ; and he receives his fee whether he accepts or rejects the 
applicant. 

The examination of an applicant for life insurance necessarily resembles, to 
some extent, the cross-examination of a witness in court. The applicant is a 
witness in his own behalf, to whom rejection would be disagreeable, if not 
depressing, and it is but natural that he should present the most favorable view 
of every doubtful point in his family and personal history. It is the duty of the 
Examiner, therefore, by careful questioning and cross-questioning, to ascertain, 
as nearly as may be, the facts. 

THE APPLICATION. 

Before making the personal examination, the Examiner should insist upon 
the absolute completion of that part of the application to be signed by the 
applicant, and should read over the questions and answers carefully with the 
applicant, and, with his aid and over his signature, complete every imperfect 
answer, and explain, so far as possible, every ambiguous word or phrase. 

Ambiguous and imperfect answers generally refer to one or more of the 
following points : — 

i. Occupation. — Common answers are: "Manufacturer," "merchant," 
"clerk," "salesman," "fireman," "engineer." From such answers as these 
the Office can form no idea of the nature of the occupation. The kind of 
business and duties must be definitely stated. 

2. Conditio?i of Health of Relatives Living. — Such answers as " fair health," 
"not very strong," etc., must be explained and the nature or symptoms of the 
trouble ascertained and stated. 

3. Causes of Death of Relatives Deceased. — Under this important head are 
often found the most ambiguous statements, such as "debility," "overwork," 
"childbirth," "dropsy," "liver complaint," "change of life," "accident," 
"nervous prostration," "some acute disease," etc. The real nature and the 
duration of the last illness must be determined, if possible, and fully explained. 

12; 



126 HOW TO EXAMINE FOR LIFE INSURANCE. 

4. The Use of Alcoholic Liquors and the Use of Tobacco, Opium, Chloral, 
etc. — In the consideration of a risk nothing is more important than the habits 
of the applicant respecting the use of stimulants and narcotics. Intemperance 
weakens body and mind, and increases the fatality of acute disease by lessen- 
ing the powers of resistance, while many forms of chronic disease take their 
origin in the excessive use of alcoholic liquors and tobacco. Moreover, the 
statistics of life insurance show that intemperance reduces the average expecta- 
tion of life nearly two-thirds. The most definite information on this subject is 
therefore required, and the Examiner should see that the answers to the 
questions relating to the use of stimulants and narcotics are clear and with- 
out ambiguity. The Company does not knowingly insure an intemperate 
person. 

5. Previous Attacks of Illness. — The nature of these attacks, together with 
their severity, dates and duration, must be fully set forth. 

6. Lisurance in other Compa7iies. — The kinds of policies are frequently not 
mentioned. They should be stated in every instance, and the length of term 
and dates of issue should also be given. 

PERSONAL EXAMINATION. 

This should take place in private, no third party being present. In making 
this part of the examination the Examiner will please observe the following 
rules and suggestions : — 

1. Height. — State the height in stocking feet, by making proper allowance 
for the heel of the shoe. If the Examiner knows his own height exactly he 
can easily determine that of the applicant by comparison. But actual measure- 
ments are always preferred. 

2. Weight. — In doubtful cases confirm the alleged weight by having appli- 
cant weighed anew. In cases of extreme underweight or overweight, ascer- 
tain whether the condition is a family characteristic ; and if it is, have applicant 
write and sign a statement, giving approximate weights of father, mother, 
brothers and sisters. 

3. Chest and Abdome?i. — In measuring the chest and abdomen, and in 
examining the organs therein contained, remove the coat, vest and suspenders, 
and in doubtful cases remove all clothing. 

4. Respiration and Pulse. — It is well to take the respiration and pulse at 
the beginning of the personal examination, as they are liable to become 
excited during the examination. Always count the pulse for at least one 
minute, otherwise intermissions in the beat may be overlooked. If the pulse- 
rate is over 85 or under 55, examine at another time. 

5. Surgical Operation. — If the applicant has undergone a surgical operation, 
always mention the disease or injury for which it was performed. 

6. Vaccination. — Satisfy yourself from the applicant's statements or by an 
examination of his arm, that he has been successfully vaccinated. Evidence 
of successful vaccination will be required in every case. 

7. Exai7tination of the Urine. Physical and Chetnical Examination to be 
made in every case. — The Examiner will ascertain and record the color, specific 
gravity and reaction of the urine, the presence or absence of albumin and 
sugar, the nature of any sediment that may exist, and, indeed, any abnormality 



MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY. \2J 

that he may find. As a general rule, the necessary information may readily 
be obtained by the aid of chemistry and the naked eye. 

On and after October ist, 1888, the Company will require the specific gravity, 
reaction, and chemical analysis of the urine of every applicant. 

A microscopical examination will be made only when the Local Examiner 
deems it advisable, or the Home Office specially calls for it. 

When the Examiner makes a microscopical examination, he will please state 
his reasons for so doing. 

Before testing the urine observe the following precautions : — 

'1. Satisfy yourself that the specimen presented was passed by the appli- 
cant, and whenever practicable, have him pass it in your presence. 

2. Examine the specimen within twenty-four hours from the time it was 
passed. 

3. Be sure that your test-tube is clean. 

4. Be sure that your reagents are trustworthy. 

5. Bear in mind that cases of advanced disease are not likely to be pre- 
sented to you, and that abnormal elements, if present at all in the urine, are 
likely to be present only in small quantities ; that, therefore, the examination 
should always be made with great care. 

Albumin. — The best test is that by heat and nitric acid. If the urine is not 
perfectly clear, it should be filtered before the test is applied, and if it is not 
distinctly acid in reaction, a few drops of acetic acid should be added. Apply 
the test as follows : Fill a test-tube three-quarters full with the urine. Boil the 
urine at the top, that a comparison may be made with the portion below which 
has not been boiled ; hold the tube against a dark background in a beam of 
sunlight. The slightest opacity indicates either albumin or earthy phosphates. 
If the cloud is phosphatic, it will disappear on the addition of a drop or two of 
nitric acid ; if it is albumin it will remain unchanged by the acid. 

Sugar. — Before applying the tests for sugar, albumin, if present in consid- 
erable quantity, should be removed by boiling and filtering. 

Trommels Test. — To a small quantity of urine in a test-tube, add two or 
three drops of a solution of sulphate of copper (1 to 10) ; then add a quantity 
of liquor potassse equal to that of the urine, and then boil for half a minute. A 
yellow, yellowish-red or red precipitate will form if sugar is present. The boil- 
ing should not be kept up more than half a minute, inasmuch as by prolonged 
boiling many organic substances besides sugar are enabled to reduce the salts 
of copper. 

Fehlings Test. — This is the most convenient test. The solution should be 
kept fresh and in a dark place. In using it, a small quantity should be boiled 
at first in a test-tube. If it remains clear after boiling, it is fit to use ; but if a 
precipitate occurs, a fresh supply must be made up, or the old solution may be 
restored by adding a little more caustic soda. Having brought the solution to 
the boiling point, add the urine drop by drop. If sugar is present in any con- 
siderable quantity, the characteristic yellow or red precipitate will take place on 
the addition of one or two drops of urine. If no precipitate occurs, go on adding 
the urine until a quantity equal to that of the test liquor has been added ; then 
bring the whole to the boiling point again, and if no precipitate forms, it may 
safely be inferred that no sugar is present. 



128 HOW TO EXAMINE FOR LIFE INSURANCE. 

Casts. — The examination for casts requires great care. Not less than four 
ounces of the urine should be taken and allowed to stand in a conical glass for 
at least twelve hours. A drop of the urine at the bottom should then be taken 
carefully by means of a pipette and placed upon the slide. The whole field of 
the slide should be studied, and the urine should not be pronounced free from 
the suspected casts until at least three drops have been taken and examined in 
this way. 

CAUSES OF REJECTION. 

The Company has no absolutely fixed rules respecting the rejection of 
applicants. Each case is decided on its own merits. The following grounds 
of rejection, however, are usually adhered to, some of them invariably: — 

i. Paralysis in any form, except, perhaps, certain forms not dependent on 
disease of the nerve centres. 

2. Vertigo, unless satisfactorily explained. 

3. Total blindness. 

4. Total deafness. 

5. Suppurative disease of the middle ear. 

6. Consumption, when three or more cases have occurred in the family. 

7. Asthma, unless it be a simple "rose cold" or " hay fever." 

8. Diphtheria, empyema, pleurisy and pneumonia, if recent or not fully 
recovered from. 

9. Haemoptysis within ten years. 

10. The pulse, when irregular or intermittent, or when above 85 or below 
55 per minute. 

11. Dyspepsia. 

12. Jaundice within a year. 

13. Hepatic or renal colic within five years. 

14. Gout within five years. 

15. Articular rheumatism within a year or when several attacks have 
occurred. 

It is expected that the Examiner will use his own unbiased judgment in 
accepting or rejecting an applicant. Whenever, for any reason, he believes 
that an applicant's chances for reaching old age are not good, he should 
decline the risk. In many instances, however, the question of an applicant's 
chances for long life is purely a question of heredity. If in doubt in such 
cases, the Examiner may approve the risk, explaining his doubts in a note, 
and referring the whole matter to the Home Office for decision. 

In order to be accepted for the whole term of life, applicants should have at 
least a fair chance not merely of living out their " expectation, but of attaining 
old age. And the reason for this is obvious when we reflect that many of the 
insured will inevitably die before their term of expectation has expired, and 
that, therefore, many others must live beyond their expectation in order that 
the loss occasioned by the premature deaths may be counterbalanced. 

It sometimes becomes apparent, before the completion of an examination, 
that the risk cannot be advised by the Examiner. In such cases the examina- 
tion should be completed as usual, and its results fully recorded, as in the case 
of advised risks. The application, in such cases, will be forwarded to the 
Home Office by the Agent. The Company will not pay for a medical exami- 



MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY. 1 29 

nation of which no record has been received at the Home Office, the applica- 
tion and accompanying Examiner's Report being the only evidence that such 
examination has been made. 

The Company is pleased to receive communications directly from its Medi- 
cal Examiners at any time concerning the cases which are brought before 
them. Information thus received will be held as absolutely confidential. 



MICHIGAN MUTUAL LIFE INSURANCE CO. 

DIRECTIONS FOR EXAMINING PHYSICIANS. 

The Medical Examiner is earnestly requested to bear in mind that he is 
appointed for the protection of the Company, that the rates for insurance are 
based upon sound lives, and to recommend no other. 

In answering the questions, he is also requested to be short and concise, 
and never convey a doubtful opinion. 

Before making an examination the Medical Examiner should carefully read 
the application for insurance. 

Questions regarding height, weight, etc., should be very carefully answered. 
If a man is much above or below the weight proportioned to his height, or has 
gained or lost weight rapidly, give all the facts in regard to the case. The 
average weight of men five feet eight inches is 148 pounds ; with a loss of from 
three to five pounds for every inch below this to five feet, and a gain of about 
five pounds for every inch up to six feet. 

The measurement of the chest should be taken under the vest. The aver- 
age expansion is about three inches. Also be particular to note if there be any 
depression in the infra-clavicular regions. 

The pulse being regular, should not be over 90 a minute, and it is suggested 
that the pulse be counted both before and after the examination, as the heart's 
action is very apt to be excited by it. 

Refer to the special " Examination Blanks " of this Company : — 

Question No. 1. — State whether robust or spare, erect or stooping, in answer 
to " Figure." 

Question No. 4. — Is a very comprehensive question. If hernia be present, 
note whether single or double. Fistula hi ano are of importance, generally 
indicating a bad condition of the system, and should reject the applicant. 

Question No. 6. — Any severe surgical operation should be investigated, and 
its effects noted. 

Question No. 8. — Can only be learned by questioning. 

Question No. 9. — The general appearance of the applicant will answer this. 
An habitual user of distilled liquors or a hard " drinker " should be promptly 
rejected. 

Question No. 10. — See applicant's family record. 

Question No. 11. — Can only be answered after a very careful examination of 
the chest, in all its parts, and is really one of the most important questions the 
Examiner is called to decide upon. Any irregular respiration should always be 
very carefully noted. 

Question No. 12. — Must be answered after questioning the applicant. The ' 
character of the sputa of a cough of any considerable duration must be noted, 
and the occurrence of the slightest hemorrhage should excite suspicion in the 
mind of the Examiner, and be looked over in all its bearings. 

Question No. 15. — Demands very careful auscultation, both at the apex and 
base of the heart. 

131 



132 HOW TO EXAMINE FOR LIFE INSURANCE. 

Questions No. 17 and 18. — Can generally be ascertained by the gait and 
manner of speech of the applicant, and by a few questions. 

Questions No. 4, 11, 12, 13, 15, 16, 17, 18, 20 and 21 are very important, 
and should have the careful attention of the examining surgeon. 

This Company instructs their agents to have examinations of applicants for 
insurance made only by medical examiners appointed upon the recommenda- 
tion of this office. 

When the Medical Examiner is absent or unable to make the examination, 
the alternate Medical Examiner may make the examination, an explanation of 
the facts accompanying the application. 

Where no Medical Examiner has been appointed, a graduate of a reputable 
medical college, a physician of experience in his profession, regularly educated, 
and of the best reputation in the place, may be called upon to examine, and a 
blank called the Medical Examiner's Credentials should be filled out and 
accompany the application in every case. No medical examination will be 
considered where these directions have not been complied with. 

The attention of Medical Examiners is called to the fact that their appoint- 
ments are intended to be permanent, and it is expected that they will give a 
serious professional consideration to each examination and select only first- 
class lives from among those presented. Where there is any doubt regarding 
the propriety of accepting the applicant, it should be decided in favor of the 
Company. In cases where the unbiased opinion of the Examiner, from 
motives of personal interest or otherwise, cannot be given upon the applica- 
tion, a confidential communication may be reported to this office separately 
by the first mail. 

The application in all cases should be carefully read, and any indefinite 
answers explained and corrected, such as " general debility," " breaking 
down," "died in the war," "exposure," "cold," "childbirth," "change of 
life," " dropsy," etc. 

The inspection of the applicant should determine his complexion and 
expression ; the freedom from puffiness of the face or feet, the absence of 
jaundice, the elasticity of gait, etc., etc. Nervous headaches, indigestion or 
dyspepsia, if reported as occurring, should be very carefully analyzed, as well 
as the habits regarding the use of alcoholic liquors. 

In cases where the extreme chest measurements are less than three inches 
expansion, an explanation will be required from the Examiner, as few good 
risks show less than this amount. 

A chemical analysis of the urine will be required in all cases where the 
applicants are forty-five years of age or over ; in all cases at any age where the 
amount of insurance is $5000 or over, and in all cases where in the judgment 
of the Medical Examiner it is, from the existence of headaches, dyspepsia, 
dropsy, pallor of the face, or from any symptoms of disease of the urinary 
organs, deemed advisable to make one. 

The Medical Examiner will be expected to obtain the specimen at the time 
of the examination, so as to assure himself of the genuineness of the sample. 
This assurance is particularly necessary in those instances where there is any 
suspicion, from any symptoms or from the personal history, that there may be 
nephritic or cystic disease. The acidity or alkalinity should be determined 



MICHIGAN MUTUAL LIFE INSURANCE COMPANY. 1 33 

with litmus paper, and in case the urine is found alkaline a second sample 
should be tried, and if still found alkaline the reason should be given. The 
test for albumin should be made with heat and dilute nitric acid ; the actual 
test made should be recorded specifically. The specific gravity should be 
tested by a float. 

In every case where the quantity passed in twenty-four hours is found 
greater than normal, the test for sugar should be made, and in every case 
where the quantity is normal and the specific gravity is higher than 1026, and 
in every case where there is excessive thirst, or where the applicant passes the 
urine with undue frequency, or is obliged to rise at night to void it, a sugar 
test should be made (Trammer's test preferred). 

The temperature of the blood taken by a fever thermometer, under the 
tongue, with the lips closed, will be required in each examination, and the 
actual observation must be recorded. 

The following are some of the conditions recognized as requiring rejec- 
tion by the Medical Examiner : — 

CAUSES FOR REJECTION. 

Family History. — 1. (a) Where both parents have died of phthisis. 

(b) Where one parent has died of phthisis and where one or more brothers 
or sisters have died of phthisis, unless applicant is over thirty-three years of 
age and resembles physically the other parent. 

(V) Where two cases of apoplexy (or paralysis) have occurred in the family. 

(d) Where two cases of heart disease or two of insanity have occurred in 
the family. 

(e) Where two cases of Bright's disease or two of cancer have occurred in 
the family. 

Personal History. — 1. Respiratory System, (a) (Constitutional symptoms 
of phthisis) ; night-sweats ; haemoptysis ; frequent pulse ; shallow breathing ; 
short hacking cough ; pallor ; general emaciation ; prominent clavicular and 
scapulas ; elevated temperature. (Physical signs), roughened breathing ; pro- 
longed expiratory murmur ; unexpansive chest ; dullness on percussion ; per- 
sistent rales in apex of lung. 

(b) Habitual cough; chronic bronchitis; pleurisy, or effects of (flattening on 
one side); asthma, within three years, or former history of; dyspnoea from 
any cause ; pneumonia, two attacks of, if associated with phthisis or struma in 
the family ; emphysema ; undue frequency of respiration (above twenty-one 
per minute when quiet). 

2. Circulatory System. Intermittent or irregular pulse; pulse above ninety 
or under fifty ; heart disease of all forms with or without a murmur ; very large 
varices extending above the knee ; pulsating varices ; aneurisms ; atheroma- 
tous or calcareous (radial) arteries ; great force of heart's action ; marked 
feebleness of heart's action. 

3. Nervous System. Previous apoplectic attack, or cerebral hemorrhage; 
paralysis, partial or complete of any member; epilepsy; vertigo; convulsions; 
insanity ; mental feebleness or debility ; insane temperament ; attempted or 
threatened suicide ; chronic otitis (shown by purulent discharge from the 
ear) ; severe chronic neuralgias of any form ; blindness, deafness, or either 



134 



HOW TO EXAMINE FOR LIFE INSURANCE. 



sufficient to produce a liability to accidents ; dipsomania, in all forms ; 
habitual tipplers, reformed drunkards, all who are accustomed to the daily 
or continuous use of distilled alcoholic liquors ; spree drinkers, or those who 
avoid liquor for some weeks or months and then use it freely for a time ; dis- 
pensers of liquors, and frequenters of places where it is used ; habitual users 
of narcotics or opiates, as chloral, opium, etc., etc. 

4. Digestive System. Dyspepsia, marked or chronic ; frequent vomiting, 
hasmatemesis, enlarged or contracted liver ; hepatic colic, within three years, 
or recurring attacks of; jaundice, postpone examination six months and if it is 
continuous reject; chronic diarrhoea; chronic dysentery; fistula in ano, within 
three years ; bleeding hemorrhoids ; hernia, unless truss is worn ; large scrotal 
hernia ; hernia, incarcerated or irreducible ; stricture of anus or rectum. 

5. Urinary System. Gravel or stone, at any time; stricture of urethra; 
cystitis ; albuminuria ; excessive quantity of urine with high specific gravity 
(over 1028) ; excessive frequency in urinating ; diabetes, any form of; haema- 
turia; Bright's diseases ; nephritic colic, within three years, or recurring attacks 
of. 

6. General Chronic Cachexy. Phthisical, strumous or scrofulous, chronic 
malarious, syphilitic cachexy ; dropsy in any form . or from any cause ; acute 
articular (inflammatory) rheumatism, history of recurring attacks of; gout; 
rheumatic gout; cancer; fibroid tumors ; tumors of all kinds ; syphilis; consti- 
tutional syphilis, acquired, or hereditary ; erysipelas, recurring attacks of. 

7. Physical Defects, Deformities, etc., etc. Loss of a leg above the knee ; 
spinal curvature, lateral or angular ; hip disease, at any time ; white swelling 
of knee, or strumous inflammation of any joint; necrosis; ulcers, psoas or 
lumbar abscess ; abscesses and fistulas of all kinds ; marked excess of weight; 
marked deficiency of weight. 



Limit Table of Weights and Measurements. 







STANDARD 


UNDERWEIGHT 


OVERWEIGHT 


HEIGHT. 


chest. 


WEIGHT. 


NOT LESS • 

THAN 


NOT TO 
EXCEED 


5 feet. 


33/2 


115 lbs. 


98 lbs. 


167 lt»S. 


5—1 


34 


120 " 


102 " 


174 " 


5—2 


35 


125 « 


106 " 


l8l " 


5—3 


36 


130 " 


in " 


188 " 


5—4 


36K 


135 " 


115 - 


I96 " 


5—5 


37 


140 " 


119 " 


203 " 


5-6 


31% 


143 " 


122 " 


207 " 


5—7 


38 


145 " 


123 " 


2IO " 


5-8 


3%y 2 


148 " 


125 " 


215 « 


5—9 


39 


155 " 


132 " 


225 " 


5— 10 


39% 


160 " 


136 " 


232 " 


5— 11 


40 y 2 


165 « 


140 " 


239 " 


6 feet. 


41 


170 « 


145 " 


246 " 


6—1 


41 y 2 


175 " 


149 « 


254 " 



MUTUAL BENEFIT LIFE INSURANCE CO. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

N. B. — The Examiners of this Company are responsible to the Company 
only, and all examinations, whether resulting favorably to an applicant or not, 
will alike be paid for. 

The Company appeals to you, as in great measure the custodians of its 
interests, to realize the responsibility involved in every examination made, and 
looks to you for a just and true estimate of the applicant, not only as regards 
his present condition, but as to his prospects for reaching his expectancy. 

To facilitate the making of such estimate, and to submit, as far as practi- 
cable, the large experience of the Company for guidance, the following rules 
and suggestions are offered : — 

Note. — In order to complete its records, the Company requires the name 
of every person examined; and when a case is not advised oris postponed 
by you, forward the reason for your opinion, by mail, directly to the Home 
Office. 

Please make your examinations in private, and have answers to all ques- 
tions in the applications, free from ambiguity. 

The terms "childbirth," "effects of childbirth," "change of life," "acci- 
dent," "debility," "acute disease," "dropsy," "worn out," "asthma," "sudden 
death," etc., will not be accepted as causes of death without full explanation. 

If ignorance of family history is urged, some proximate idea of causes of 
death should be gleaned and stated by you as Examiner. 

Inquire particularly regarding the following points in the family record : — 
i st. Have there been two cases of apoplexy, paralysis, heart disease or 
brain affection, or one of each pathologically akin? 

2d. Have there been two cases of Bright's disease or cancer ? 

3d. Have any two members been insane ? 

The following points are of especial importance to a Life Insurance 
Company : — 

1. HABITS. 

The habits of an applicant as regards the indulgence in malt or spirituous 
liquors, opium or tobacco, have been found in the experience of the Company 
of great importance. 

As you are aware, many of the diseases of vital organs are insidiously 
developed from this cause. 

Please, therefore, question each applicant on the subject ; and no matter 
what his asseverations (for the intemperate man rarely confesses his excesses), 
be assured that the liver, stomach, kidneys and nervous system are free from 
the tell-tale evidences of indulgence. The Company should always be informed 
when an applicant uses liquor daily, even if in moderation, and the quantity, 
whether of beer, wine or spirits. 

135 



I36 HOW TO EXAMINE FOR LIFE INSURANCE. 

II. COMPLEXION AND BUILD. 

The physique and complexion are important factors in determining the 
prospects of an applicant : a flat chest, a pigeon breast, a protuberant abdo- 
men, local muscular atrophy, disproportionate height and weight, excessive 
height, a stooping gait, a curved (angular or lateral) spine, are all serious evi- 
dences of impairment. 

A waxen look of the ears, puffiness of the eyelids, peculiarity of speech, and 
the cachexia of cancer or scrofula, are too well known to you to be more than 
casually mentioned, but all such conditions should be clearly reported. 

If the applicant's abdomen is larger than the chest, note and record the 
measurement ; if fat, ascertain the rapidity of increase. Extreme fatness or 
leanness are significant, and should be stated under the head of weight. Exact 
and not approximate measure?nents are necessary. (See table of averages of 
height and weight.) 

III. EXAMINATION OF URINE. 

A microscopical examination of urine should be made in addition to the 
usual chemical tests, when the amount asked will make the total insurance in 
this Company $10,000 or over (blanks will be supplied for this). If the appli- 
cant has been subject to headache or neuralgia, irritation of the skin without 
eruption, swelling of the feet or nausea, examination by microscope will usually 
be found necessary, and fee for same will be allowed if the Examiner certifies 
that such additional precaution is necessary ; but in cases of recent renal 
derangement, of severe or suspicious character, and especially if there has 
been gravel, bloody urine or the cachexia of Bright's disease, the Company 
should not be put to the expense of even an ordinary examination of the 
applicant. 

The following hints upon examination of the urine are submitted as a re- 
minder of points frequently overlooked or forgotten : — 

In testing for albumin remember that the cases most likely to be pre- 
sented are those in which the albumin is in minute quantity. 

Be sure that the urine is slightly acid, and if not so, add a little acetic acid. 

Be sure of the cleanliness of the tube. 

Boil the liquid at the top, holding it thereafter against a dark background in 
order to detect a very slight cloudiness. Allow the specimen to stand awhile if 
clear after boiling, and the same after adding nitric acid, as the cloudiness due 
to albumin may not always be immediately evident. 

Heller's test for albumin should also be employed. 

This is as follows : — 

Place in a wide test-tube pure concentrated nitric acid to a depth of half an 
inch. Then add the urine with a pipette, drop by drop, carefully allowing it to 
run down the sides. A thin white line of demarcation will indicate the pre- 
sence of albumin. (For rare exceptions, see authorities.) 

In testing for sugar, Fehling's, or the fermentation test are preferred. 

In using the former it is important to be sure that Fehling's solution itself 
gives no deposit on boiling. 

The following evidences of impairment are a bar to insurance : — 

1st. Asthma, within three years, except where produced by external causes 



MUTUAL BENEFIT LIFE INSURANCE COMPANY. 1 37 

similar to that of hay or rose asthma, or by certain employments which have 
been permanently relinquished. 

2d. Gravel or calculus within three years. If more than one attack, five 
years. 

3d. Gall stone within five years. 

4th. Consumption in the family, as follows : — 

(a) Where more than three cases have occurred. 

(/>) Where the applicant is under 20 and one case has occurred. 

(l) Where under 30, and a parent has had consumption (except for a 10- 
year endowment when otherwise favorable). 

(d) Where under 35, and any two members have shown the disease. 

(V) Where under 40, and both parents have had the disease. 

CO Where over 40, and both parents have had the disease (except for an 
endowment to terminate prior to his reaching sixty years of age, when the case 
is otherwise favorable). 

5th. Haemoptysis, whether slight or profuse, within ten years. (If a longer 
interval shall have elapsed, the Home Office shall decide according to the 
otherwise favorable conditions of the case.) 

6th. Empyema, pleurisy and pleuro-pneimionia, if recent, or if their results 
are not entirely recovered from. 

7th. Pneumonia, if recent and with a single case of consumption in the 
family. (If more than one attack shall have been experienced by the appli- 
cant, five years must elapse from the date of the last recovery.) 

8th. Curvature of the spine, lateral or angular, recent or of long standing. 

9th. Diphtheria, if recent. 

10th. Dyspepsia, if the applicant has or is subject to it. 
nth. Rheumatic gout within three years and gout within five years. 
12th. Vertigo within two years, if the applicant is over forty. (In any case 
it must be clearly described, both as regards cause and character, that the 
Home Office may decide.) 

13th. Dropsy, habitual cough, ulcers, fits, and organic diseases of liver or 
kidneys within seven years. 

Paralysis from lesion of brain or spinal cord. 

Intermittent or irregular pulse. 

Rheumatism, acute articular, within one year. 

Rheumatism, chronic or subacute, crippling or muscular ; if recent, protracted 
or severe. 

Discharges from the ear (recurrent or chronic). 

Pulse habitually above 90 or below 50. 

Hernia (unless a proper truss can and will be worn). 

Hernia, irreducible. 

Varices of extremities, extending above the knee or of unusual size. 

Recent or existing fistula. 

Inefficient vaccination. 



138 



HOW TO EXAMINE FOR LIFE INSURANCE. 



The Following Table Shows the Expectation of Life 
for the Different Ages : 





EXPECTATION 




EXPECTATION 




EXPECTATION 


AGE. 




AGE. 




AGE. 






OF LIFE. 




OF LIFE. 




OF LIFE. 


IO 




38 


29.62 


57 


16.05 


20 


42.20 


39 


28.90 


58 


15-39 


21 


41-53 


40 


28.18 


59 


14-74 


22 


40.85 


41 


27-45 


60 


14.09 


23 


40.17 


42 


26.72 


61 


1347 


24 


39-49 


43 


25-99 


62 


. 12.86 


25 


38.81 


44 


25.27 


63 


12.26 


26 


38.11 


45 


24-54 


64 


11.68 


27 


37-43 


46 


23.80 


65 


11. 10 


28 


36.73 


47 


23.08 


66 


10.54 


29 


36.03 


48 


22.36 


67 


10.00 


30 


35-33 


49 


21.63 


68 


9.48 


31 


34.62 


5o 


20.91 


69 


8.98 


32 


33-92 


51 


20.20 


7o 


8.48 


33 


33-21 


52 


19-49 


7i 


8.00 


34 


32-50 


53 


18.79 ' 


72 


7-54 


35 


3I-78 


54 


18.09 


73 


7.10 


36 


31-07 


55 


17.40 


74 


6.68 


37 


30.35 


56 


16.72 


75 


6.28 



Ft. 


In 


5 


O 


5 


I 


5 


2 


5 


3 


5 


4 


5 


5 


5 


6 


5 


7 



Table of Averages of ' Height and Weight. 

In. 



lbs. 


Ft 


115 


5 


120 


5 


125 


5 


130 


5 


135 


6 


140 


6 


H3 


6 


145 





9 

10 

11 

00 

1 

2 



lbs. 
148 

155 
160 
I6 5 
170 

175 
180 



Note. — In cases of great excess of weight or the opposite, a full and explicit statement 
will be required regarding the physique, general appearance and average weight during the 
past seven or eight years, together with information as to rapidity of loss or increase. 



THE MUTUAL LIFE INSURANCE COMPANY 
OF NEW YORK. 

INSTRUCTIONS TO THE MEDICAL EXAMINERS. 



The Medical Officers of the Mutual Life Insurance Company of New York 
present the following instructions to its Medical Examiners : — 

The Medical Examiner's relation to the applicant for life insurance is oppo- 
site to that which he occupies in his professional capacity. In the latter case 
the patient exposes his infirmities, and even intensifies them ; the applicant 
for life insurance, on the other hand, may desire to lessen their importance or 
conceal their existence. 

The Medical Examiner is the guardian of the interests of the Company. He 
is expected to furnish the Company, on its appropriate blanks, an explicit and 
truthful statement of the age and physical condition of the person proposed for 
insurance, and to revise the statements made in the application, with a view to 
demonstrating their correctness. For this reason he receives a fee, whether the 
applicci7it be accepted or rejected. 

He should be careful to give a clear statement of the circumstances apper- 
taining to each case. If any disease or disorder has occurred, name it specifi- 
cally, avoiding such phrases as " urinary trouble," " kidney difficulty," "throat 
disorder," "complications," etc. These terms, conveying no precise informa- 
tion, produce an unfavorable impression as to the risk, and cause additional 
correspondence and delay. 

The Examiner should report any local causes of disease which makes resi- 
dents unhealthy, and also whether there is anything in the occupation render- 
ing life insecure. Persons not unfrequently change their residence and busi- 
ness for sanitary reasons. Such reasons must be investigated. 

If the applicant has ever applied, or been examined, for life insurance, and 
no policy issued, explanation of the reason for such non-issue of policy must 
be given, with date of rejection and name of company. 

EXAMINATION OF THE PERSON PROPOSED FOR INSURANCE. 

g^*" This must always be made in private and apart from the Agent. 

The Examiner should notice whether the age given corresponds with the 
appearance of the person, and when marks of premature decay are present, 
should report them. He should also notice whether the person be erect, well- 
formed, and of healthful aspect ; and whether the height be in proper propor- 
tion to the weight. 

If the applicant be over the standard weight, state whether it is caused by 
fat, or by development of bone and muscles ; and whether the party is of active 
or sedentary habits. If, on the contrary, the person applying for assurance be 
under the standard weight, it is important to know whether his tissues be firm 

139 



I40 HOW TO EXAMINE FOR LIFE INSURANCE. 

or relaxed. In either case, state whether the underweight or overweight is or 
is not a family characteristic. 

Defects of vision and hearing may be of serious import, either as of them- 
selves impairing the risk, or as indicating disease of vital organs. 

Any injury, mutilation or deformity must be reported. 

The regular or occasional use of intoxicating liquors, tobacco or narcotics, 
needs special investigation, as experience has proved that habits of drinking, and 
the use of narcotic agents, have more influence in determining the probability of an 
individual attaining average longevity than any other factor in the problem of 
life insurance. 

It is better to rate the pulse in the sitting posture, and note its qualities before 
the exploration of the chest shall have excited the circulation. 

It often happens that from exercise or the taking of food or stimulants just 
previous to the examination, the pulse becomes rapid, unsteady or even inter- 
mittent. The use of tobacco, strong coffee, tea, or the loss of a night's rest will 
sometimes produce the same results. Always postpone such cases for sub- 
sequent examination, when the cause being removed, the circulation may be 
found normal. In case frequency alone be the objection, by prolonging the 
interview and diverting the applicant's mind from the immediate subject in 
hand, the pulse will become fuller and its frequency decrease. 

The Examiner should exercise great care in his exploration of the thorax, 
remembering that he has probably only to detect the first symptoms of thoracic 
disease. No examination can be satisfactory that is made through the clothing; 
the chest must in all cases be exposed, or, at least, only covered by the under- 
garment. 

The history of an attack of haemoptysis should not be looked upon as 
accidental, unless distinctly coincident with some injury inflicted or some 
violent physical effort made at the time. It is often stated that the bleeding 
came from the gums or throat; but the presumption is always against this 
origin, and it must be proved to the satisfaction of the Examiner before the risk 
is approved. 

Dyspepsia is sometimes a prelude to consumption or organic disease of the 
stomach or kidneys. Its nature should in all cases be inquired into and 
reported upon. 

Symptoms of disease of the urinary organs (stricture, enlargement of the 
prostate gland, stone, etc.) should be carefully investigated. 

In many instances predisposition to disease may be acquired from habits of 
life, occupation, exposure, accidents, unhealthy residence, previous attacks of 
disease, etc. It is the duty of the Medical Examiner to make a close examina- 
tion of all the facts bearing upon such cases, and to state in the application, or 
in private letter to the Medical Officers, such modifying circumstances. 

If the applicant has suffered from any recent severe attack of illness, post- 
pone his acceptance until a sufficient time shall have elapsed to show his 
restoration to firm health. 

THE FAMILY RECORD 

is often carelessly reported, and the frequency with which parents, brothers or 
sisters die of " old age," "exposure," "childbirth" "change of life," "dont 
know," and similar ambiguous causes of death, has made the Company 



THE MUTUAL LIFE INSURANCE COMPANY OF NEW VORK. 141 

desirous of getting specific information, unembarrassed by vague or unscientific 
terms, upon these vital points. 

In some cases the applicant may be really ignorant of the diseases and even 
the exact ages of his near relatives. If so, let the Examiner state this fact. 

Predisposition to disease is regarded under two aspects. 

1 st. Where the family history is such that the person may be considered 
predisposed to the disease of which his parents died — as, for instance, where 
the death of both was the result of consumption, insanity or so-called 
" scrofulous " disease ; and 

2d. Where one parent and a number of brothers and sisters or other 
relatives have so died, conjoined with personal predisposition to the disease. 

In cases where one parent has died of disease, the predisposition to which in 
the offspring may be hereditary, the person, by reason of age, conformation, 
health and occupation, with an affinity to a healthy parent, may be fairly 
entitled to an endowment policy for a limited term of years. 

Observe, also, hereditary or acquired tendencies to other diseases, especially 
rheumatism, heart disease, gout, cancer, Bright' s disease, insanity, syphilis and 
nervous diseases, as well as the general family tendency either to longevity or 
to death at an early age. 

GENERAL REMARKS. 

A general question should be asked, embracing all such diseases as may 
have been omitted or may be known to the person by other names than those 
given in our form of application. Many diseases of importance have been 
omitted (as malarial and typhoid fevers), which may have left serious impres- 
sions on the constitution ; on the contrary, such diseases as smallpox and 
scarlatina, after complete recovery, tend to improve the risk. 

Whenever a medical examiner postpones or declines an application, he will 
please write a confidential letter to the Medical Department of the Home Office 
at once, giving the person's name, age, occupation, and the reason for his 
action. 

If, for any reason, the Examiner does not wish to present in the application 
certain specific facts disclosed by the examination, he must write a confidential 
letter to the Medical Department at the Home Office, detailing such informa- 
tion. In this way nothing of importance affecting the risk need be withheld 
from the Home Office. 

If information as to the present or past condition of the applicant be deemed 
necessary, it is desired that the Examiner procure it from the applicant's attend- 
ing physician in a professional way, with the understanding that it will be 
treated as confidential by the Company. Such information should be paid for 
by the Examiner as a regular office fee, and the amount thus paid communi- 
cated in a private letter to the Medical Officers, who will cause it to be 
refunded. 

When the application is for $30,000 or over the applicant must be examined 
by two regular examiners. 

The rule governing the examination of the urine is as follows : — 

The urine must be examined for sugar when the specific gravity is 1025 or 
over. Applicants for amounts under $30,000 are to be examined by one 
Examiner, and no microscopical examination of the urine is to be made 



142 HOW TO EXAMINE FOR LIFE INSURANCE. 

except when required by the Company. Applicants for insurance amounting 
to $30,000 and over require two physical examinations, two chemical examina- 
tions and one microscopical examination of the urine. Applicants for $50,000 
and over require a double physical examination, two chemical and two micro- 
scopical examinations of the urine. The urine thus examined must be passed 
by the applicant at different times. 

women's applications. 

If the applicant is a woman, ascertain whether the functions of the repro- 
ductive system are normal. 

Owing probably to the difficulty of ascertaining the peculiar physical history 
of women in their applications, the experience of life insurance companies is 
that they have not generally proved to be profitable risks. Consequently, it is 
necessary to make their physical examination with the greatest care. 

In cases of pregnancy, postpone the application until a sufficient time has 
elapsed after delivery to indicate that the woman's constitution has not been 
affected. 

RULES AND REGULATIONS. 

1st. The Company's latest issue of blank form of application must be used 
in all cases, and every question fully answered. 

2d. Applicants cannot be examined by Medical Examiners who are either 
their relatives or who may be directly or indirectly beneficiaries under the policy. 

3d. Applicants must be examined in the town where they reside or do busi- 
ness, and by the Examiner regularly appointed and accredited to such town. 
When the Medical Examiner is himself the applicant, he must be examined by 
another Medical Examiner regularly appointed in the same or in a neighbor- 
ing place. 

4th. Particular attention should be paid with regard to writing out the full 
name of the person examined. 

5th. The Medical Examiner's Report should be free from alterations, inter- 
lineations or erasures. When unavoidable, the same must be duly attested by 
the party entitled to make them, with date of such attestation. 

6th. Medical examinations, to be accepted, must have been made within 
thirty days prior to the receipt of the application at the Home Office. 

7th. The Company holds the Medical Examiner responsible for the identi- 
fication of applicants, and he is instructed to make no examination unless the 
applicant is personally known or satisfactorily introduced to him. The same 
rule applies to persons presented for examination for certificates of health, 
which, in all cases, must be paid for by the applicant and must not be charged 
to the Company. 

8th. A Medical Examiner who removes from the district to which he has 
been accredited, forfeits his appointment. He may, at the discretion of the 
Company, be reappointed for the district to which he has removed, provided 
there is a vacancy at that point. 

9th. The Medical Examiner must invariably date his examination at the 
time when it was made. 

10th. A Medical Examiner may solicit applications for insurance and par- 
ticipate in the commissions accruing therefrom under the rules of the General 



THE MUTUAL LIFE INSURANCE COMPANY OF NEW YORK. I43 

Agency in which he resides, but he must, in every such instance, submit the 
applicant to another regularly appointed Examiner for examination. It is 
manifestly improper that he should act as Examiner and Agent at the same 
time. 

nth. An Examiner who signs as witness to an applicant's signature should 
state the reason therefor, and whether he has any interest in the transaction. 

i2th. Considering them especially hazardous risks, this Company will not 
insure the following : Gamblers, bar-keepers, hotel proprietors who attend their 
own bars, keepers of saloons where liquor is sold, keepers of billiard parlors, 
or any individual who may be engaged in retailing alcoholic drinks or person- 
ally in the manufacture of the same ; miners, day-laborers, engineers and fire- 
men, whether of stationary or moving engines ; men employed on any railroad 
train or in switching or coupling cars ; men in blast furnaces, powder mills, fire- 
works or nitro-glycerine manufactories ; balloonists, ordinary seamen, men 
operating in steam mills or in the vicinity of circular saws ; divers or submarine 
workers of any kind. 

It is respectfully suggested to the Medical Examiners that they should 
promptly notify the officers of the Company of every case where a policy- 
holder may be violating the terms of the policy by vicious habits or otherwise 
in a way tending to shorten life. By compliance with this request unjust claims 
may be avoided. 

FEES. 

1st. The fees for examination allowed by the Company, in each case will be 
paid by the Agent, and should be receipted for on the Company's blank. But, 
should the application be for less than $1000, the fee must be paid by the appli- 
cant. 

2d. The additional fee for a microscopical examination of urine — where 
required by the foregoing rules — will be the same as that allowed for the 
physical examination of the applicant. 

3d. When examinations by two physicians are required (in cases between 
$30,000 and $50,000) but one microscopic examination of the urine shall be 
made, for which but one fee will be allowed, as per rule. 

4th. But one fee will 'be allowed for any number of examinations of the same 
applicant made within thirty days. 

5th. Medical Examiners will be paid only the regular fee for examinations. 
All extra charges, as for transportation, or going unusual distances, must be 
paid by the Agent. 

6th. The Company will decline to pay for the examination of any applicant 
whose occupation is described in the foregoing rules as especially hazardous. 
The Medical Examiner must look to the Agent for his compensation where the 
applicant is so excluded. 

7th. Bills for medical examination must be presented at the end of the cur- 
rent month. 

RULES GOVERNING PROOF OF DEATH. 

A. Specific information concerning the habits of the late deceased, in regard 
to the use of alcoholics and narcotics, must be furnished ; and also the occu- 
pation must be fully stated. 



144 



HOW TO EXAMINE FOR LIFE INSURANCE. 



B. When death is caused by disease of the brain, or from insanity, give the 
full particulars as to the cause and duration of the same. 

C. In case of suicide, a certified copy of the evidence and verdict before the 
Coroner is required; and in all cases of sudden death from unknown causes, 
the particulars and results of all investigations held must be sent to the Com- 
pany. 

D. Certificates of the disease causing death must be furnished by the attend- 
ing and consulting physician. 

E. Every question must be distinctly and fully answered. The Company 
reserves the right to ask additional questions when necessary. 

New York, March 12 ; i8go. 

The following table is inserted for the convenience and information of the 
Medical Examiner : — 



Table of the Proper Proportion of the Height of 
Individuals to Their Weight. 



height. 


STANDARD 


20% UNDER 


45% OVER 


CHEST. 




WEIGHT. 


WEIGHT. 


WEIGHT. 




5 Feet, 


"5 


92 


167 


33A 


5 ' 


1 In. 


120 


96 


174 


34 


5 ' 


2 " 


125 


IOO 


l8l# 


35 


5 ' 


' 3 " 


130 


IO4 


188^ 


36 


5 ' 


' 4 " 


i35 


I08 


195 


3^A 


5 ' 


' 5 " 


140 


112 


203 


37 


5 ' 


< 6 " 


143 


II 4 


207 


31% 


5 ' 


' 7 " 


H5 


Il6 


2IO 


38 


5 ' 


< 8 " 


148 


11 9 1 A 


215 


3%% 


5 ' 


< 9 « 


155 


124 


224>^ 


39 


5 ' 


' 10 " 


160 


128 


232 


39 l A 


5 ' 


l jj u 


165 


132 


239 


4-o}4 


6 < 




170 


136 


246 


41 



NATIONAL LIFE INSURANCE COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

1. All Medical Examinations must be made by our regularly appointed 
Examiners in the place where the applicant resides. 

2. When the Examiner is himself the applicant the examination must be 
made by another regularly appointed Examiner in the same or neighboring 
town. 

3. An applicant cannot be examined by an Examiner who is his relative, 
or who is any way interested in the issuance of the policy. 

4. When the application is for more than $10,000 two examinations are 
required. 

5. The application must be received at this office within thirty days from the 
date of the examination. 

6. The Examiner must date his examination on the day it is made. 

7. The Medical Examiner has duties to perform which directly involve the 
welfare of the Company, and he is expected to perform them in a careful and 
conscientious manner. 

His report should be full and exact, each question being definitely answered, 
and the answers free from alterations, interlineations or erasures. 

8. The examination, except when the applicant is a female, should be con- 
ducted in private, and no matter how well known to the Examiner the person 
may be, or how vigorous his appearance, he should in every instance be thor- 
oughly examined. 

9. Owing to the fact that so many applicants endeavor to conceal their 
infirmities or to lessen their importance, it is a safe rule to regard every person 
as diseased until a complete examination proves him to be otherwise. 

10. Identification. — The Examining Physician should make no examination 
until he is sure the party presented for examination is the person named in the 
application. 

n. Occupation. — The occupation of the applicant must be fully stated in 
the report. Avoid indefinite terms, as " clerk," "merchant," etc., but state the 
particular branch of business. 

In every case satisfy yourself that the applicant is not personally engaged in 
the manufacture or retailing of wine, spirits or malt liquors. This Company 
now regards such people uninsurable. 

12. Family History. — As indications of the existence and character of hered- 
itary influences, the health and duration of life of near relatives are important 
items. We seek for evidence of transmissible diseases in the grandparents, 
parents, uncles and aunts, brothers and sisters, and the children, if any, of the 
applicant. 

These questions should be carefully answered, and in giving causes of death 
the specific disease should be elicited. Vague and unscientific terms, as " old 
age," "change of life," "exposure," "liver complaint," etc., should be avoided. 

10 i 45 



I46 HOW TO EXAMINE FOR LIFE INSURANCE. 

In every case state whether phthisis was or was not the cause of death. 

13. Personal Health. — The questions regarding personal health should be 
asked and answered separately, and if there is a history of serious illness, its 
character, date of occurrence, and duration, with any injurious effects that may 
remain, should be definitely stated. Much correspondence and delay will be 
avoided if the Examiner gives precise answers to these questions. 

The pulse should be examined in the sitting posture, its frequency, rhythm, 
volume, strength and tension being noted. When the pulse is found to be 
intermittent, irregular or unsteady, or when its rate is below 60 or above 90 per 
minute, postpone the case for subsequent examination and in your report state 
the condition fully and plainly. 

The chest must be thoroughly examined for evidences of disease of the 
organs of respiration and circulation. 

No examination can be satisfactorily made through the clothing. The chest 
should be exposed in every case. 

14. Habits. — The habits, past and present, of the applicant, as to the use of 
alcoholics, opium and tobacco, should be determined. Avoid such terms as 
"moderately," "occasionally," " not to excess," etc., but endeavor to ascertain 
the exact amount of stimulants taken. Their frequent use should direct atten- 
tion to the stomach, liver, kidneys and nervous system. 

15. Exami7iation of Urine. — The urine must be examined in every case. 
The color, daily quantity, specific gravity, reaction, and the presence or ab- 
sence of albumin and sugar, are the essential points to be determined. If the 
specific gravity is found to be below 1010 or above 1030 a second examination 
should be made. 

For the detection of albumin the nitric acid test (Heller's) and the heat and 
nitric acid test, where the proper precautions are observed, are sufficiently 
accurate. 

Fehling's Solution, as prepared by Dr. Squibb, is a reliable test for sugar. 

16. Conjideiitial. — When the circumstances of the case are such that the 
Examiner hesitates to give his full estimate of the risk in the report, he is 
invited to correspond with the Home Office, where all communications are held 
strictly confidential. 

17. Rejection. — Whenever the Examiner declines an application, or when 
he refuses to examine a man on account of family or personal history, he is 
requested and expected to write to the Home Office, giving full name, date of 
birth, where born and occupation, date of his unfavorable action and reason for 
same. 



NEW ENGLAND MUTUAL LIFE INSURANCE 
COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

1. You will in every case act entirely in the interest of the Company, bearing 
in mind that upon you devolves the professional responsibility of protecting it 
against undue eagerness of agents to introduce doubtful risks for the sake of 
their commissions. 

2. If you should chance to be the regular medical adviser of the person 
whose application is under consideration, you will state the fact, which should 
not, however, prevent an examination, unless objection is made thereto by 
either the agent or the applicant. 

3. If an application on the life of a female is presented, you will make 
as thorough a personal examination as the circumstances will admit, and 
inquire in regard to any disease, or symptoms of disease, she may have had, 
peculiar to her sex, or to which she maybe liable before attaining the age of 47 
years. 

4. If the person applying is a male of the age of 40 years or over, your 
attention will be particularly directed to the constitutional diseases of that 
period of life when the " tendency is to urinary diseases ; to fatty degenera- 
tions; to cardiac and other obstructions from undue deposits, apoplexies, 
paralyses, and the like." And it would be well in all such cases to present 
to the Company a clear view of your impression as to the muscular ability 
and vital force of the applicant, the rule being, that " when a person has 
aged beyond his years, the risk is greatly impaired." 

5. Every fact bearing favorably or unfavorably upon the risk, whether of 
family record or personal history, should be mentioned, in order that strict 
justice may be done to the person applying, and no wrong inflicted upon the 
Company. If the person be over weight, or larger around the waist than over 
the chest, a fact due to the accumulation of fat or muscle, it should be men- 
tioned, because an excess of fat may depreciate, while a predominance of 
muscle may improve, the character of the risk. If spare for his height, if 
hollow chested or stooping, or possessing any peculiarity, physical or other- 
wise (intermittent pulse, for instance), which may, in your opinion, have a 
bearing upon the risk as affecting its approval or rejection, you will be 
expected to state it. 

6. For the purpose of ascertaining the existence of, or predisposition to, any 
hereditary disease on the part of the applicant, you will carefully investigate 
his or her family history, satisfying yourself among other matters that where 
"childbirth," "general debility," or "dyspepsia" is said to have been the 
cause of death, such was actually the case. This designation has sometimes 
been given ignorantly, or with design, when early deaths have followed 
pulmonary complaints or cancer of the stomach. 

By the statistics of mortality nearly yi of all deaths are from " Consump- 

147 



I48 HOW TO EXAMINE FOR LIFE INSURANCE. 

tion;" and in the best regulated Life Companies of the country from % to 
*4 of the deaths are annually from the same cause ; hence the importance of 
detecting those answers ignorantly or willfully made, which bear upon the value 
or depreciation of the risk. 

7. Prior to every personal examination, you will direct the applicant's 
attention to the importance, of his carefully reading the questions, and the 
answers thereto, for it has been found that solicitors have imposed upon 
innocent parties by conveying to them the impression that the application 
was a mere matter of form. 

8. You will make no personal examination in any locality where, from noise 
or interruption, the sounds of the heart and the respiratory murmur cannot be 
distinctly heard. Postpone, rather than make an imperfect examination ; occa- 
sionally cases will occur where even two examinations must be made before a 
decided opinion can be given. 

GENERAL REMARKS. 

One of the questions in the certificate which you are required to fill with the 
results of your examination and investigation is this : — 

" Is the person, in your opinion, as good a life for insurance as the average 
of persons of the same age, who are of sound constitution, in good health, and 
whose family history is good ; and do you, acting in the interest of the Com- 
pany, advise the acceptance of the risk ?" (Please certify to this directly and 
specifically, yes, or no. ) 

The mistake which many Examiners make is in giving their opinion upon 
an entirely different average than that inquired about ; one will say the appli- 
cant is as good as persons in general ; another, that he is as good as the aver- 
age of persons who apply for insurance ; neither of which is the average the 
Company desires to obtain. Such answers throw no light upon the value of 
the risk, and present nothing reliable in the way of information. It is impos- 
sible that a medical man, unless he be in a position to examine every applica- 
tion that is made, can know what constitutes the average of persons applying 
for insurance, and so with the " average of persons in general," the same rule 
will apply in a greater or less degree according to the information which one 
possesses of mortuary statistics. But there can be no difference of opinion as 
to what constitutes the average of persons of the same age in sound health and 
of good constitution. By reason of thorough medical examinations, the lives 
that enter into a company are better than the general average ; that is, the 
mortality among assured lives is less than that among the general population. 
The maintenance of this selection is the great security of Life Insurance Com- 
panies. 

" If the Medical Examiner will bear in mind the great influence that selection 
has upon the lives of a company in general, he will not form his estimate of 
the risk lightly, nor give an answer to the important question above mentioned, 
without taking into consideration every fact which bears upon the case. A 
hasty decision made from a personal examination only, without taking into 
account the family record, or the diseases to which the applicant is subject, is 
productive of procrastination and trouble, if not of actual injury." 

If you are aware of any facts, bearing unfavorably upon the risk, which you 



NEW ENGLAND MUTUAL LIFE INSURANCE COMPANY. I49 

may not care to notice in the certificate, you are at liberty to state them in 
a confidential note. 

This Company will accept the examination of no physician who has not 
been regularly appointed for that purpose ; and no Medical Examiner will be 
retained who is not found to be scrupulous and faithful in guarding its interests. 

This appointment is subject to a revocation for satisfactory reasons. 



NEW YORK LIFE INSURANCE COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS.* 

If, after any examination, the Medical Examiner decides to report adversely 
upon the case, he is requested, before he sends his examination to the Com- 
pany or Manager, or delivers it to the Agent, to write the Company confi- 
dentially, giving the name, date of birth, and occupation and residence of the 
applicant, together with the reason for his unfavorable opinion ; and blanks 
for such cases are sent every Medical Examiner with this pamphlet. 

If, for any reason, the Medical Examiner prefers to do so, he is authorized 
and requested to send his reports direct to the Home Office ; nor is it necessary 
that he should report or disclose to any one the result of his examination. 

The following remarks are offered, not as medical instructions, but rather as 
practical suggestions to those among our Examiners who are not familiar with 
making examinations for life insurance. 

They are not intended to prescribe in full the duties of Medical Examiners, 
but to point out the manner in which examinations may be most readily and 
effectively made. They should be regarded as a confidential communication 
from the Medical Department of the Company to each Examiner personally. 

In return, our Examiners are requested to communicate directly and confi- 
dentially with the Medical Department at the Home Office of the Company, at 
any time and in all cases where, in their opinion, it is desirable or necessary. 

Any information from them in regard to the climate, epidemics, hygiene or 
diseases peculiar to the localities in which they reside, will be welcome and 
highly appreciated. 

LIFE INSURANCE — THE APPLICANT. 

Life insurance is protection. It protects those dependent upon the insured 
from the financial loss involved in his untimely death ; it relieves him from the 
pecuniary responsibility connected with the great uncertainty of human life by 
transferring that responsibility to the company in which he insures. 

The business of Life Insurance is based on the fact that, while the longevity 
of a single individual is proverbially uncertain, there is a fixed law determining, 
within narrow limits, the average age at death of large numbers of individuals 
of the same age ; and that, under this law, it may be expected that any man in 
sound health, of temperate habits, with a good family history and a healthful 
occupation, will live as long as the average of those of the same age, i. e. t will 
live out his " Expectation of Life." 

Involving, as it does, the purely medical questions of the past and present 
health, the family history, the habits, hygienic surroundings and occupation of 
the individual, the Life Insurance business requires for its successful prosecution 
the assistance of those whose lives are spent in the study of such questions — 
Medical Practitioners ; and because of the enormous sums of money involved, 

*The matter here presented is a revision of the last edition of instructions issued by 
this Company. 

151. 



152 HOW TO EXAMINE FOR LIFE INSURANCE. 

and the dangers of fraud, it is necessary that the Medical Examiners of a Life 
Insurance company should possess, besides a good medical knowledge, the 
most upright character and sound judgment. 

The chief essential to the success of a Life Insurance Company is the main- 
tenance of a high standard in the selection of its risks. These should always 
be fully up to the average in health, of temperate habits, of good personal 
and family history, and of healthful occupation ; and they should approximate 
closely to the average physical conformation of healthy men. Of the health, 
habits, history and occupation of an applicant for insurance, physicians are 
able to fully inform themselves ; but the questions o£ average physical confor- 
mation or "build," and of the average probable longevity of an individual, so 
rarely present themselves for their attention, that the following tables will be 
found of convenience for reference : — 

THE BUILD 

of an individual (his height and weight) aids to determine his longevity, and it 
has been found that, other things being equal, his "Expectation of Life" is 
increased the nearer an individual approaches to the average proportions of 
height and weight, as they are given below : — 

A man 5 feet o inches in height should weigh 115 pounds. 
" " 120 " 

125 « 
130 " 

135 " 
140 

145 " 
150 

155 " 

" " 160 " 

" " 165 " 

" 170 

175 " 

180 " 
185 

« tt I90 « 

A considerable variation from these averages (as much as 20 per cent.) is 
not, however, incompatible with an average " Expectation of Life." 
The following is the table of 

THE EXPECTATION OF LIFE. 
A man 20 years old may be expected to live 42 years, or until 62 years old. 

" 25 « " " 

« 30 « « « 

" 35 

u 40 « « « 

" 45 

" 50 " " " 

« 55 « ^ « 

60 " " " 



5 


" 1 


5 


" 2 


5 


" 3 


5 


" 4 


5 


" 5 


5 


" 6 


5 


" 7 


5 


" 8 


5 


« 9 


5 


" 10 


5 


" 11 


6 


" 


6 


" 1 


6 


" 2 


6 


" 3 



39 " 


" 


64 


35 " 


« 


65 


32 " 


" 


67 


28 " 


el 


68 


24 " 


" 


69 


21 " 


u 


7i 


17 « 


<< 


72 


14 " 


" 


74 



NEW YORK LIFE INSURANCE COMPANY. 1 5 3 

The foregoing tables are given, not as arbitrary standards, but only to 
enable the Medical Examiners of the Company to GAUGE and RATE, from a 
Life Insurance standpoint, the risks which they examine. 

MEDICAL EXAMINERS. 

The Medical Examiners are selected solely for their moral and professional 
standing in the communities in which they reside. They hold their appoint- 
ments direct from the Company, and retain their positions as long as their ser- 
vices prove satisfactory to it. 

They are the trusted advisers of the Company, and their relations with the 
Medical Department are personal and confidential. It is their duty to examine 
every applicant for insurance presented to them by the Agents of the Com- 
pany, to furnish, on blanks provided for that purpose, full and complete reports 
of the personal and family histories and of the physical conditition of the appli- 
cants, and to give their opinion as to the value of the risks. For each of these 
examinations they receive a fixed fee, and this fee is paid whether the applicant 
is approved or disapproved by the Examiner. The fees are paid by the Com- 
pany and not by the applicants or Agents ; and the Examiners are in no sense 
dependent for their appointment, dismissal or their fees upon either applicants 
or Agents. 

It is to the interest of all concerned that the relations of the Examiner toward 
both the applicants and Agents should be cordial and friendly. Toward the 
applicants for insurance his position is of the same delicate and confidential 
character as that toward the patients who entrust themselves to his professional 
care ; and while it is often the duty of the Medical Examiner to oppose his judg- 
ment to the wishes of Agents by refusing to recommend some of the applicants 
for insurance, yet the Medical Examiner, by the exercise of tact and judgment, 
and especially by firmness in his convictions, ought to avoid all friction, and 
thereby secure that harmony so essential to a pleasant and profitable intercourse 
and to satisfactory business results. 

To the Agents belong the task of securing applicants for insurance, thus 
bringing new business to the Company ; and to the Medical Examiners that of 
selecting from such applicants only those risks which may be safely accepted 
by the Company. 

In ordinary medical practice the patient endeavors to describe fully and 
clearly the history and every detail of the disease of which he complains, so as 
to give the physician a complete understanding of his condition. He conceals 
nothing from him, and the physician has only to consider the evidence before 
him and, rejecting that which is worthless, to act upon that which is reliable 
and of value. 

In examinations for life insurance, on the contrary, the applicant wishes to 
appear well and strong. He declares that he is in sound health, and in all his 
statements as to his personal and family history, he is inclined to emphasize 
only those features which appear to him favorable to his case ; and when the 
applicant is dishonest, he tries to mislead the Examiner, and so distorts the 
facts that it becomes very difficult to draw a correct conclusion from them. In 
short, a patient assists his physician; an applicant for insurance frequently 
antagonizes the Medical Examiner. 



154 HOW TO EXAMINE FOR LIFE INSURANCE. 

Therefore, besides the skill of the ordinary practitioner, the Examiner for 
life insurance must bring to his task complete independence of character, abso- 
lute integrity, and the tact to recognize all attempts at fraud on the part of 
applicants or others interested in the risk. He must constantly bear in mind 
that he is the guardian of the interests of the Company, and that upon his 
vigilance, judgment and integrity depend largely its success or failure. 

MEDICAL EXAMINATIONS. 

The medical examination of an applicant for life insurance has for its object 
to secure such information in regard to the family history and the past and 
present health of the applicant as will enable the Medical Board at the Home 
Office, assisted by the opinion of the Medical Examiner, to judge whether the 
Company may safely assume the risk of granting the insurance applied for. 
This object is best secured by following a routine which has been found by 
experience to produce the most satisfactory results. The steps in this routine 
may be illustrated by describing in detail the method of conducting an exami- 
nation at the Home Office of the Company. 

When an applicant presents himself for examination, or is brought by an 
Agent, the Examiner receives him with courtesy, takes him alone into his pri- 
vate office, provides him with a comfortable seat, and begins the examination 
by reviewing in detail the statements made in the application as to his full name, 
the date of birth, occupation, etc., and satisfies himself as to the identity of 
the applicant, and that the application is correctly filled out and properly 
signed. 

Then the questions are asked as to the diseases from which the applicant 
has suffered, and the answers are fully and clearly set down. All obscurities 
in the history of any illness or disease are carefully investigated, until the Ex- 
aminer is fully satisfied as to their importance and bearing on the probable 
longevity of the applicant. 

The family history is inquired into, and here the Examiner is most careful 
to set down fully the age and condition of health of the living, and the age and 
cause of death of each deceased member of the applicant's family, especially in 
the direct line, and having always in view the importance of recognizing any 
hereditary disease. 

This completes the " Declarations made to the Medical Examiner," and 
the paper is then signed by the applicant in the presence of the Examiner. 

The Examiner then turns to the "Medical Examiner's Report," and sets 
down the full name, age and occupation of the applicant, and makes such other 
of the required memoranda as maybe possible without disturbing him. During 
this time the applicant has remained quietly seated, and, assisted by the tact 
and courtesy of the Examiner, has overcome that nervousness so natural to any 
one when subjected to a medical examination. 

While the applicant is thus seated at his ease, the Examiner notes the number 
and character of his respirations, and examines his pulse, observing its rapidity, 
volume and rhythm, and noticing especially the character of the vessels and 
the condition of their walls. 

The applicant having then removed his coat and vest, the Examiner weighs 
him, and measures his height and the circumference of his chest and abdomen, 



NEW YORK LIFE INSURANCE COMPANY. 1 55 

and, the clothing having been arranged for that purpose, proceeds to the physical 
examination of the chest. He notices the si/e and position of the heart, and 
carefully studies its action and the character of its sounds. He observes the 
character of the percussion note and of the respiratory sounds over every part 
of both lungs, and when he suspects any abnormality, in order to avoid possible 
error, requests the applicant, before continuing the examination, to remove such 
other portions of his clothing as may be necessary. 

If the applicant has given a history of disease of any other organs of the 
body, the Examiner pursues his investigations until entirely satisfied as to 
their present condition, and carefully notes whatever changes he may have 
found. 

Having completed the physical examination, he notes any scars or marks 
which would serve to identify the applicant, and selects and records the most 
striking and characteristic of them. At the same time, if there has been any 
doubt about the successful vaccination of the applicant, he carefully looks for 
a scar and satisfies himself on that point. 

He now requests the applicant to furnish him with a specimen of his urine, 
and takes care that no deception is practiced, and that it is voided by the appli- 
cant himself. 

This completes the examination and, while the applicant is readjusting his 
clothing, the Examiner reviews his report, to be sure that he requires no further 
information. He then courteously dismisses him, referring to the details and 
the result of the examination, or not, as seems, in his judgment, advisable. 

Then, having made the necessary examination of the urine, he proceeds, at 
his leisure, to complete his report. He weighs deliberately all the factors in the 
case, and, having arrived at a conclusion as to the value of the risk, writes 
down his decision, recommending the applicant as "First-class," "Good" or 
"Fair;" or refusing altogether to recommend the risk, as the results of his 
examination and deliberation require. 



To prevent delay and the necessity for correspondence with Examiners, 
which will inevitably arise if they make mistakes or omit any important details 
in their examinations, the Medical Department submits the following 

RULES FOR CONDUCTING EXAMINATIONS, 

which must be carefully observed by the Medical Examiners of the Company. 
i. Privacy. — The examinations shall be made in private, and no Agent or 
any third person allowed to be present. 

2. As to the Application. — Before the medical examination is begun, the 
application blank shall be completely filled out, all questions answered and 
signatures affixed ; and the Examiners shall see that the questions are perfectly 
understood by the applicant and the answers fully and truthfully made. 

3. As to Clearness. — In both the "Declarations" and the " Examiner's Re- 
port," all questions shall be fully, clearly and separately answered, though as 
briefly as possible, and all doubtful points explained. 



I56 HOW TO EXAMINE FOR LIFE INSURANCE. 

4. Of Personal History. — A positive statement shall be made of each of the 
diseases from which an applicant has suffered. All indefinite terms, such as 
" slight cough," " slight dyspepsia," " bilious headaches at times," etc., must be 
avoided. If worthy of mention, the disease must be fully described. 

Note. — The utmost care should be taken to give a complete history of such 
diseases as rheumatism, gout or syphilis ; the date of each attack, the character 
and severity of its symptoms, its duration and sequelae, should all be fully set 
forth. The importance should be kept in mind of distinguishing chancroid from 
true chancre ; and when there is a history of gonorrhoea, the presence or 
absence of a stricture of the urethra should be noted. 

Whenever the Examiner is unable to fully satisfy himself as to the influence 
on the probable longevity of the applicant of any disease from which he has 
suffered, the Examiner should request the applicant to furnish the Company, 
on a blank provided for that purpose, a " Certificate of the Usual Medical At- 
tendant" as to the disease in question, and, if possible, should attach such Cer- 
tificate to his report. 

5. Of Family History. — The details of the family history, especially with ref- 
erence to hereditary diseases, shall be fully set forth. Such indefinite causes 
of death as "general debility," "change of life," "dropsy," "fever," "child- 
birth," "exposure" or "accident" must be avoided or, if given, must be so 
explained by the Examiner that the existence or non-existence of hereditary 
disease will be clearly established. 

6. Examination of Women. — In the examination of women, the Medical 
Examiners shall be quite as thorough as in the examination of men, and in all 
cases they shall furnish, on the special blank provided by the Company, a 
separate report on the condition of the organs of generation. 

Note. — The experience of most Life Insurance Companies with female 
risks has been unfavorable, chiefly because of a want of thoroughness in the 
examinations. The Medical Examiners of this Company should take care to 
avoid the possibility of such results. 

7. As to the Use of Alcohol. — The past and present habits of the applicant 
as to the, use or abuse of alcohol must be carefully and explicitly stated. 

Note. — This is a question of fact whose importance in Life Insurance can- 
not be overestimated. When the applicant is a stranger, the Examiner, by 
questioning and cross-questioning, ought to get at the exact truth ; and when 
he is personally known to the Examiner, an incorrect answer is inexcusable. 
The Company never knowingly accepts risks on the lives of persons not habitu- 
ally temperate. 

8. A Chemical Examination of the Urine shall be made in all cases, and 
the Medical Examiner must satisfy himself that no deception is practiced upon 
him, and that the urine which he examines is that of the applicant. 

Note. — A microscopic examination may be made whenever any features in 
the history or examination make it clearly necessary to the Examiner before he 
can decide as to the character and the risk. For such microscopic exami- 
nation, carefully made and reported, the Company allows the Examiner an 
additional fee. 

9. As to Corrections. — Whenever the Medical Examiner finds it necessary to 
make any corrections, interpolations or erasures, in either the " Declarations" 



NEW YORK LIFE INSURANCE COMPANY. I 57 

or " Report," he shall acknowledge each of them by placing opposite it his 
initials or signature. 

Note. — A strict observance of this rule is necessary in order to avoid all 
doubt as to the authenticity of such corrections. 

10. The Decision of the Medical Examiner shall be rendered only after a 
careful study of all the facts in the case, and, as the Company issues no form 
of policy on persons ill with any acute or chronic disease, such as bronchitis, 
emphysema, heart disease, albuminuria, or the like, he shall not recommend 
such persons for insurance, or shall recommend them only for a period safe to 
the Company, or shall be governed by Rule n. Where the Examiner is in 
doubt, he must give the Company the benefit of such doubt. 

Note. — Before giving his decision on any case, it is well for the Examiner 
to ask himself the questions : Whether he would, as a private individual, take 
precisely such a risk upon his own account, and would he himself insure the 
life of the applicant ? And whether he would advise the Company to place 
hundreds of similar risks upon its books ? 

ii. The Decisions Need not be Amiounced. — In any case where the Exami- 
ner thinks it necessary or desirable, or whenever his own business or personal 
relations with the applicant or Agent are of such a character that he does not 
wish to express fully in the examination papers his opinion of the risk, (a) he 
may forward all the papers direct to the Home Office instead of through the 
agent or manager ; or (b) the Company will accept a supplementary report 
mailed to the Home Office. Such report, however, to be of value, must reach 
the Home Office before— certainly not later than — the application 
itself* 

Note. — On account of the complications which are liable to arise, it is 
requested that Medical Examiners avail themselves of this rule only when 
necessary for their protection, or for other special reasons. 

For the convenience of the Medical Examiners of the Company, the follow- 
ing remarks are added in regard to 

THE EXAMINATION OF URINE. 

As quickly as possible after it is passed, the specimen of urine of the appli- 
cant for life insurance should be examined with respect to each of the following 
points : — 

i. Quantity in 24 hours. 4. Reaction. 

2. Color. 5. Transparency. 

3. Specific Gravity. 6. Albumin or Sugar. 

7. Microscopical Appearances of the Sediment. 

1. The Quantity of urine passed by an adult in good health may be stated 
at about 45 to 50 ounces in 24 hours ; but it is subject to variations within con- 
siderable limits, depending upon such conditions as the temperature and hu- 
midity of the atmosphere, the activity of the skin, the amount of the expiratory 
exhalations, and the amount of fluids or of liquid foods ingested. 

* See also Special Notice. 



I58 HOW TO EXAMINE FOR LIFE INSURANCE. 

In disease it varies from the enormous quantities passed in diabetes, in 
hysterical polyuria and in the amyloid and the old granular kidney, to the 
scanty flow of the febrile state and of some forms of disease of the kidneys. 

2. The Color is usually a pale yellow or amber, though it varies with the 
quantity of urine voided. With a copious flow the color is very pale ; with a 
scanty flow it may be very dark. 

In disease it varies from the dark, smoky-brown of acute Bright's disease, 
through the high-colored urine of the febrile state, and the pale straw color of 
diabetic urine to the almost colorless urine of the hysterical state and some 
cases of contracted kidney. 

3. The Specific Gravity of urine may be stated at 1020, under ordinary cir- 
cumstances, although it may vary in health between 1010 and 1025, dependent 
upon the same causes as those which influence the variation in quantity and in 
color. Since the amount of solids excreted by the kidneys is fairly constant, 
this variation in specific gravity is approximately in inverse ratio to the amount 
of urine voided. 

The specific gravity is best obtained by means of the urinometer. This 
instrument is usually graduated between 1000 (the specific gravity of dis- 
tilled water) and 1060, and, when used, care has to be taken that it is perfectly 
clean and that it does not cling to the side of the vessel in which the test 
is made. 

In disease this range is increased. In diabetes it may be 1040, 1050 or 
higher. In the earlier days of acute Bright's disease, and in the febrile state, 
it is high, and from that it ranges to that of the cirrhotic and the amyloid kid- 
ney, of diabetes insipidus or of the hysterical state, where the specific gravity r 
may be 1005 or less. Since, however, urine with specific gravity 1010 has been 
found to contain sugar, and since the normal specific gravity has often been 
noticed in old cases of Bright's disease and in severe diabetes, the specific 
gravity cannot be relied on as an accurate guide to disease. But an average 
daily specific gravity of 1025 or over is always suggestive of the presence of 
sugar, and of 1015 or under of old Bright's disease. 

4. The Reaction of normal urine is usually acid — due, probably, to acid 
phosphate of soda — but it may be neutral or alkaline. 

The reaction is determined by the use of litmus papers. The red becomes 
blue in the presence of an alkaline urine, and the blue paper becomes red if 
the urine is acid. When the reaction is not well marked, both the red and 
blue papers should be used. The acidity of urine is increased by an albumin- 
ous diet, and vegetable foods decrease it or render the urine alkaline. 

In disease the acidity is decreased in anaemia and in some nervous affec- 
tions, and is increased in diabetes and fevers. 

5. Transparency. — The urine is naturally transparent, but, within the limits 
of health, it may be more or less opaque on account of the presence of 

(a) Earthy Phosphates, (c) Mucus, 

(b) Mixed Urates, (a 7 ) Bacteria. 

(a) The earthy phosphates may cause normal urine, at the moment it is 
voided, to be opaque. Shortly afterward they subside and form a bulky, floc- 
culent sediment, with clear urine above. They may be recognized by the fact 



NEW YORK LIFE INSURANCE COMPANY. 1 59 

that the application of heat will increase the opacity, while a few drop, of nitric 
or acetic acid will cause it to disappear. 

(b) The mixed urates often render a cold urine turbid. They subside quite 
rapidly and form a white or pinkish deposit at the bottom and on the sides of 
the containing vessel, much more dense in character than that of the phos- 
phates. A gentle heat causes this opacity to disappear. 

(c) Mucus from the genito-urinary tract may occur in sufficient quantity, 
within the limits of health, to cause some opacity in the urine. It forms a light, 
fiocculent sediment, much like that produced by the phosphates, but which 
may be distinguished from the latter by the fact that alkalies, heat and strong 
acids have no effect upon it, while acetic acid increases the opacity by coagu- 
lating the mucin. 

(d) Bacteria. — When a specimen of urine is allowed to stand for some time, 
especially in hot weather, it becomes opaque, on account of beginning decom- 
position and the development of bacteria. This change is important because it 
interferes with the delicacy of the tests for albumin, and it is on this account 
that a specimen of urine should be examined while fresh. 

When it becomes necessary to examine for albumin a specimen of turbid 
urine, which is not rendered transparent by filtration, it should be treated by 
the method suggested by Hofman and Ultzman, which is as follows : Add to a 
portion of the urine, in a clean test-tube, about one-quarter its volume of liquor 
potassas ; boil the mixture, and filter. Should this filtrate be not quite clear, 
add one or two drops of magnesian fluid,* warm again and filter. This fil- 
trate always appears clear and transparent. The presence of albumin may 
then be detected by the nitric acid test. 

In disease, the urine may be opaque on account of the presence of — 

(a) Pus. — This forms a deposit which often resembles that of the urates. It 
is distinguished from it by the fact that heat increases the opacity of purulent 
urine, and from phosphatic deposit by the fact that it is not cleared up by the 
addition of a few drops of acid. 

(b) Decomposition, as in old cases of cystitis, in which the urine contains 
bacteria, pus, mucus, epithelium and, perhaps, shreds of disorganized tissue. 

(c) Fat, as in chylous urine. Fat is recognized by the well-known power 
of ether to dissolve it. 

6. (a) Albumin. — The presence of albumin in the urine is always suggestive 
of such grave pathological conditions that its recognition becomes one of the 
most important features in the examination of urine. Many tests have been 
brought forward for this purpose, and have had their earnest advocates, but 
those which "have become most generally recognized for simplicity and effect- 
iveness are the nitric acid test and the heat test. 

The Nitric Acid Test. — Into a clean test-tube about half an inch of pure, 
colorless nitric acid is poured. The test-tube being then held at a considerable 
angle, a quantity of clear urine is allowed to flow from a pipette slowly down 
the inclined side of the tube, until an inch of urine overlies the acid. This 



* The formula of the magnesian fluid is as follows: Magnesium sulphate and ammo- 
nium chloride, of each one drachm ; liquor ammonke, one drachm ; distilled water, one 
ounce. Mix. 



l6o HOW TO EXAMINE FOR LIFE INSURANCE. 

must be carefully done, so that there there shall be no mixture of the acid and 
the urine. The presence of albumin is indicated by a sharp, white band or 
zone of coagulated albumin in the urine at the line of contact of the acid with 
the urine. In order to recognize this band, where the amount of albumin is 
small, the tube should be held in a good light against a dark background. 
Sometimes this zone of coagulated albumin develops very slowly, and it is, 
therefore, always well to look at the specimen again 15 minutes after the test 
is made, having placed it carefully aside for that purpose. 

Errors. — A specimen of urine which contains a large amount of urates may 
show a whitish zone above the line of contact. This is caused by the formation 
of acid urates, and is distinguished by the fact that the zone is not so sharply 
defined as that formed by albumin, but fades gradually into the clear urine ; 
also, because it disappears on the application of a gentle heat. 

The presence of resin, not unusual after the use of such drugs as balsam of 
copaiba, turpentine, etc., produces a whitish zone similar to that produced by 
albumin. The addition of a few drops of alcohol will redissolve the resin. 

The Heat Test for Albumin. — A clean test-tube is filled about two-thirds full 
of slightly acid urine. To the upper part of this urine, heat is applied by means 
of a spirit-lamp. If, when the urine has boiled, any diminution of transparency 
is noticed, it is due to albumin or the earthy phosphates. If to the latter, a few 
drops of acetic acid will cause the opacity to disappear ; if to albumin, the addi- 
tion of the acid will have no effect. 

Error. — If the urine is slightly turbid from decomposition and the presence 
of bacteria, any delicate change in the opacity cannot be seen, and it must be fil- 
tered before applying the heat. If, after filtration, it still remains turbid, it should 
be treated according to the suggestions already made under $d, Bacteria. 
If the specimen is alkaline, acetic acid should be cautiously used, and if strongly 
acid, liquor potassse may be added, so as to render the urine only slightly acid. 

If albumin is not found in a specimen of urine subjected to both of these 
tests, it may be safely affirmed that it is not present. 

(d) Sugar. — Although many excellent authorities maintain that the presence 
of a small quantity of sugar in the urine may be entirely physiological, yet it 
is so often the first evidence of diabetes that its recognition is of the utmost 
importance in examinations for life insurance. 

Of the various tests which have been devised for this purpose, the copper 
test — as in the form of Fehling's Solution* — and the bismuth test, deserve 
special mention. 



* Fehling's Solution is made after the following formula: 3464 grammes of c. p. 
sulphate of copper are dissolved in 200 grammes of distilled water; 173 grammes c. p. 
neutral tartrate of soda are dissolved in 500 grammes of sodic hydrate of a sp. gr. 1. 1 2, 
and to this alkaline solution the copper solution is slowly added. The mixture is then diluted 
to one liter. The solution is made and sold by all the large drug houses. Perhaps the 
best preparation is that put up by Dr. E. R- Squibb, of Brooklyn, N. Y., and the Medical 
Examiners of the Company are requested, whenever possible, to use this preparation. 

Whenever it is impossible to obtain a reliable preparation of Fehling's Solution, a 
fairly good substitute for qualitative work may be made as follows: I drachm of sulphate 
of copper, 2 drachms of neutral tartrate of potash, 3 ounces of liquor potassae. Mix. 
Keep this closely corked and in a cool, dark place. It is to be used as detailed above 
for Fehling's Solution. 



NEW YORK LIFE INSURANCE COMPANY. l6l 

The composition of Fehling's Solution is based upon the fact, not only thai 

sugar has the property of reducing the oxide of copper to a lower state of 
oxidation, but also that a definite quantity of the former will react upon a 
known quantity of the latter (i c.c. of Fchling's Solution is reduced by .005 
gram of sugar), and it is equally useful for qualitative and quantitative analysis. 

It is an alkaline fluid, of transparent, deep blue color, somewhat easily 
decomposed* by exposure to the air and to light and warmth, therefore requir- 
ing, for its preservation, to be kept in small, closely-stoppered bottles, in a 
cool, dark place. 

The Test. — A small quantity of the solution is poured into a clean test-tube, 
diluted with two or three times its volume of pure water, and boiled for a few 
seconds over a spirit-lamp. If the mixture becomes turbid, or a yellow or brick- 
red precipitate forms, it has probably been kept too long or has been improperly 
prepared. If, however, the mixture retains its transparent, deep blue color, it 
may be relied upon, and the test is proceeded with. To the hot mixture the 
urine is added, drop by drop, and heat is occasionally applied, until a volume 
of urine has been added equal to the volume of the mixture. If sugar is 
present in quantity, the first few drops will usually cause a yellow opacity to 
appear, which spreads through the mixture, changing slowly to red as it settles 
to the bottom of the test-tube. A small quantity of sugar causes this reaction 
to take place more slowly. If no reaction takes place, the urine, clinically 
speaking, is free from sugar. 

Errors. — a. The urine must be fresh. A small quantity of sugar may fail 
to cause the reaction in an ammoniacal urine. 

b. Albumin interferes with the reaction and must be removed before the test 
is made. This may be done by heating the urine, previously rendered only 
faintly acid, and filtering it. Care must be taken not to boil the specimen too 
long. 

c. The changes produced by the earthy phosphates must not be confounded 
with the sugar reaction. The former produce a flocculent precipitation in the 
midst of a transparent, greenish amber fluid. 

The Bismuth Tests are based upon the fact that the action of sugar upon 
the bismuth salts is the same as upon the salts of copper. They have the 
advantage over the copper tests of being less sensitive to the decomposing 
power of other organic compounds. 

The Test which is ordinarily employed (Boettger's) is conducted as follows: 
The urine is mixed with an equal volume of liquor potassae or sodae, a small 

* To avoid the tendency to decompose which characterizes the alkaline solutions of 
copper, a very excellent plan is to prepare the copper solution separately, and to mix 
them when the test is made. 

The following formulae furnishes such a solution : — 

R . Sulphate of copper, 4.3 grammes 

Distilled water, 62.5 c. c. M. 

R. Tartrate of soda and potash, 21.5 grammes 

Soda, 7.5 

Disulled water, 62.5 c. c. 

Mix exactly equal parts of these solutions, pouring the copper solution slowly into the 
alkaline solution. 
II 



1 62 HOW TO EXAMINE FOR LIFE INSURANCE. 

quantity of bismuth subnitrate is added, and the mixture is boiled for a short 
time. If sugar is present, insoluble black oxide of bismuth is formed and 
deposited on the sides of the test-tube ; or if the quantity of sugar is small, 
the white bismuth powder becomes tinged with gray. 

Errors. — Only a very small quantity of bismuth should be used, as an excess 
of bismuth, if the amount of sugar is small, may conceal reaction. 

If albumin is present in the urine, a reaction due to the formation of the 
black sulphide of bismuth may take place, which resembles that produced by 
sugar, and may be mistaken for it ; the albumin, therefore, should be removed 
from the urine before the test is made. 

Another Test, which is very satisfactory, is that recommended by Nylander, 
in which bismuth is used in solution,* The test is conducted as follows : To a 
small quantity of this solution in a clean test-tube, heat is applied, and urine is 
slowly added until the quantity of urine added is equal to the quantity of the 
solution used. If sugar is present, the mixture becomes slowly clouded, and 
turns gradually darker until, if sugar is present in considerable quantity, it 
becomes wholly or quite black. When the quantity of sugar is very small, the 
reaction is much less distinct. 

To insure greater certainty in all doubtful cases, both the bismuth and 
copper tests should be employed. 

7. Microscopical Excmiination. — The apparatus necessary for the micro- 
scopical examination of the urine are : (1) a conical glass, very broad at the top 
and very narrow at the bottom, of a capacity of 4 fluid ounces; (2) several cut- 
glass slides; (3) a few thin cover-glasses; (4) a pipette; (5) a microscope with 
two objectives, §■" to i // and \" to y ', two eye-pieces, and a good concave 
mirror for illuminating the field. The urine to be examined is allowed to stand 
from six to twelve hours in a conical glass, carefully covered from the air and 
dust by means of a piece of glass or cardboard. A few drops of sediment are 
then taken up in the pipette and transferred to a clean slide placed upon the 
stage of the microscope. With the low-power objective, the field is carefully 
searched for epithelial, blood or pus cells, mucus, renal tube-casts or other 
pathological bodies. Generally, the presence of these may thus be detected. 
If not, or where the character of the sediment requires further study, one or 
two drops are taken up in the pipette, transferred to a fresh slide, covered with 
a clean cover-glass, and with the high-power objective — and, if necessary, the 
second eye-piece — the study is continued. These procedures are repeated 
several times, so that a large amount of sediment may pass through the field 
of the instrument. An examination thus conducted ought to reveal anything 
of clinical importance in the sediment. 

Whenever there is any special reason to suspect pathological changes in the 
genito- urinary tract, not revealed in the first examination, it is well to make 

* The formula of this solution is as follows : — 

R. Bismuth subnitrate (c. p.), 2 grams or 3 ss 

Potassii et sodii tartrat. (c. p.) 4 grams or % j 

Liquor sodii hydrat. (10 per cent, solution in distilled 

water), 100 c. c. or gxxvii. 

Dissolve by the aid of gentle heat and decant. Use the supernatant fluid. 



i 



NEW YORK LIFE INSURANCE COMPANY. 1 63 

several subsequent examinations at intervals of a few days, but such extended 
and repeated examinations must not be made at the charge of the Company. 

In conclusion, we submit these suggestions for the consideration of the 
medical gentlemen to whose hands, as its Medical Examiners, and as such its 
confidential advisers, the Company entrusts the grave responsibilities of their 
position, with the hope and belief that they will sustain in the future, as they 
have in the past, the honor of their profession, and ably protect the interests 
of the New York Life Insurance Company. 



NORTHWESTERN MASONIC AID ASSOCIATION. 

INSTRUCTIONS FOR OUR MEDICAL EXAMINERS. 

In order to protect our Examiners, we have divided our blank applications 
in two parts, so that the portion containing the Medical Examiner's report is 
mailed by him directly to this office, and not passed over to the scrutiny of the 
solicitor. In addition, we send out confidential reference blanks to from three 
to five of the applicant's acquaintances ; so that it is impossible for the appli- 
cant or the solicitor to positively fix the responsibility of a rejection on any one. 
A vast deal of annoyance in regard to rejected applicants is due to the disap- 
pointment or partisanship of thoughtless solicitors ; hence the importance of 
our present method of not allowing them to see the doctor's report. It would 
be a good plan to impress upon applicants the fact that rejecting is done at the 
Home Office, and that we have other means of information than your report. 

When a man makes application for membership in a mutual assessment 
company, he does it with a distinct understanding that he must come up to the 
standard required of applicants, in order to gain admission. So when the 
physician, contrary to his better judgment and in a spirit of indifference, 
recommends a poor risk, he does injustice to many other members by con- 
tributing thus far to the disintegration of an organization that is doing great 
good. While physicians experienced in the practice of their profession are 
best fitted to examine for life insurance, the physician that has skill and expe- 
rience in life insurance examinations is better fitted to practice his profession, 
on the old principle that " you must understand health before you can under- 
stand disease." It is by comparing the applicant to the normal man that you, 
in your mind's eye, determine his ability to attain his expectancy. 

Don't lose sight of your first impression regarding a risk, nor let the circum- 
stance of finding him better than you expected put you off your guard in pass- 
ing on his fitness as a risk. Although family and personal history, habits, 
occupation and location are important factors to be considered in the summary 
of every case, the plain, practical, common-sense question : Can I conscien- 
tiously, on my professional honor, recommend this applicant as a sound, 
healthy man, likely to live out his expectancy, and could I, in the interest of 
the Company, recommend twenty like him ? is the test to decide your fitness 
for the position of medical examiner. 

Familiarize yourself with copy of our blank application enclosed. Form A 
is to be filled by the solicitor, and signed by the applicant. You should always 
look at this to see whether or not his age, occupation or previous history of 
rejection, as given under the head of " Risks not Acceptable," precludes your 
examination of him. In form B you record applicant's answers and explana- 
tions to questions in the first person. In writing his answers down do not use 
ditto marks, but write plainly " yes " or " no ; " and remember, a copy of this is 
sent him with his certificate, so it is important to give the answers correctly and 
explain even what seems to be trivial. Witness his signature to this part of the 
blank. Following form B on the application proper you will note blank for the 

165 



l66 HOW TO EXAMINE FOR LIFE INSURANCE. 

Examiner to record personal description of applicant, pulse rate, etc., and 
should be filled while he is present. The Examiner's report should be filled 
and mailed immediately after the departure of the applicant, while the points 
in his examination are still fresh in your mind. Do not postpone or neglect 
it, because we cannot act on the application or credit your fee until this is 
received. Remember, your report is confidential and must be forwarded by 
you. 

It is always desirable that examinations be conducted in your office and in 
private ; not in the presence of the solicitor or others. Remove the coat and 
vest ; and if you do not deem it necessary or expedient to strip the applicant, 
throw his suspenders off his shoulders and roll the starched or upper shirt 
under his chin. You can now conveniently note contour and expansion of his 
chest and examine heart and lungs. You have already ascertained his family 
and personal history, and can give close attention to any suspicious indication. 
For instance, to the lungs if there is personal history of pneumonia or pleurisy, 
or family history of consumption ; to the heart if there is a history of rheuma- 
tism or heart disease ; to the liver and stomach if an habitual user of alcoholics 
or a chronic victim to malaria. 

Please note carefully our list of risks not acceptable, as. we cannot pay for 
the examination of such, unless the solicitor has the consent of this office to 
have an exceptional case examined. Also read carefully the list of those whose 
acceptance is questionable, as you will be expected to give full and explicit 
explanations. Attach additional sheet of paper if you have not room to write 
on the blank portion of the application and report. 

RISKS NOT ACCEPTABLE. 

Masons who have reached their fiftieth birthday, and non-masons who have 
reached their forty-sixth birthday ; saloon keepers or wholesale liquor dealers 
who keep any kind of a bar in their place of business ; locomotive engineers 
and firemen ; members of fire departments in large cities ; tug-men ; members 
of life-saving crews ; fishermen on sea or lakes ; miners ; common sailors ; 
switch-men ; yard-men ; conductors or brakemen on freight or construction 
trains ; those handling explosives ; those known to be notoriously intemper- 
ate ; persons under thirty who have lost a parent or one or more brothers or 
sisters by consumption ; persons who have had spitting of blood within ten 
years ; persons who have been rejected by this Association or by any life insur- 
ance company within two years. 

QUESTIONABLE RISKS. 

The following diseases or conditions are serious objections to insurance, and, 
in most cases, causes for rejection. Applicants who have had rheumatic fever 
or gout within one year, or several attacks during life ; persons who have ever 
had spitting of blood ; persons who have had fistula or chronic ulcers, if not 
perfectly healed more than two years ; those who have had any form of cancer, 
dropsy, habitual cough, fits, vertigo or organic disease of heart, liver or kid- 
neys ; those who have had gravel within three years ; those who have curv- 
ature of spine ; those who have been subject to asthma, other than hay 
fever, within three years ; persons who draw pensions on account of disease or 



NORTHWESTERN MASONIC AID ASSOCIATION. 1 67 

present physical disability ; intermittent, or irregular pulse, or when the pulse is 
below 55, or where it remains for half an hour above 90; purulent discharge 
from the ear ; urethral stricture or enlarged prostate ; double hernia and single 
hernia in a subject who cannot and does not intelligently manage a truss, and 
where the occupation is unfavorable ; persons who have had apoplexy, paraly- 
sis, epilepsy, tertiary syphilis or delirium tremens ; those in whom there is a 
personal history or suspicion of insanity, or where there is a marked hereditary 
or family tendency to this disease, or to suicide, especially from father's side of 
the family ; persons who are 20 per cent, under weight, especially if they have 
lost near relatives by consumption ; those who are 30 per cent, over weight, 
especially if they are fat and have lost near relatives by heart disease or apo- 
plexy, or are themselves high livers, of sedentary occupations. 

SPECIAL SUBJECTS. 

1. Consumption. — Although it is generally considered that after 35 years of 
age persons of consumptive families are less liable to the disease, and while 
this is true to a certain extent, it is by no means a safe rule. Hence the 
importance of careful selection at any age. The proportion of deaths from 
consumption seems to be greater among those who have lost brothers or sisters 
by the disease than where they have lost a parent or grandparent. Always 
ascertain the age of applicant at the time of parents' death ; also, as near as 
you can, the age at which an uncle or aunt may have had the disease, and 
whether on paternal or maternal side. Where there have been deaths from 
pneumonia, bronchitis, change of life or childbirth, obtain full history, so that 
we may determine whether or not it is another name for consumption. In 
regard to any hereditary disease, ascertain at what age in parent's life the 
disease was developed, and if applicant was born before or after the mani- 
festation of disease in the parent. 

2. Cancer. — In case where an applicant has lost a relative, even a parent, 
from cancer, if you can exclude any predisposing tendency to consumption, 
you can pretty safely ignore any hereditary tendency to cancer among the male 
members of the family. 

3. Apoplexy, Heart Disease and Centric Paralysis, for convenience, may be 
classed together, and can probably be found traceable to hereditary influence 
in about one-third of the cases. Any history, either past or present, also any 
tendency, such as recent vertigo, intemperate, rheumatic or gouty history, 
overweight, high living with deficient exercise for any length of time, or such 
influences as may lead to fatty degeneration of vital organs or atheromatous 
changes in the blood vessels, associated with a suspicious family history, will 
reject. If you find with the above conditions a feeble circulation and respira- 
tion, with history of general debility or rapid obesity, you may suspect fatty 
degeneration or urinary disease ; and if an extremely hard pulse, with over- 
weight and intemperate or rheumatic history, you may suspect atheromatous 
changes. This I believe to be the explanation of a good many of our deaths 
that are put down to unknown, obscure or complicated causes. And when 
Examiners report on their professional judgment and impressions, even in the 
absence of tangible reasons, notwithstanding applicant may have what the 
laity term a robust appearance, they will surely become the guardians of the 



1 68 HOW TO EXAMINE FOR LIFE INSURANCE. 

companies employing them, and we will have fewer deaths among recent 
applicants from such indefinite causes as paralysis of the heart, angina pec- 
toris, general debility, congestion, dropsy, etc. 

4. Vertigo. — Where there is a history of vertigo, be thorough in your investi- 
gation as to its origin. We have had more than one death from apoplexy where 
the Examiner was positive that a previous vertigo was caused by a digestive 
disturbance. Bear in mind that in centric or brain vertigo, the surrounding 
objects seem to move, and closing the eyes relieves this symptom, while in the 
reflex variety, when the eyes are closed the patient himself seems to move. 
However, in either kind, well-marked cases of recent occurrence would better 
be postponed if applicant is past 40 years of age. 

Bright 's Disease and Diabetes. — As heretofore, we are still convinced that 
we are justified in leaving urinalysis to the judgment of our Medical Ex- 
aminers, believing that in the very great majority of cases there is something 
in applicant's appearance or personal history that will suggest its advisability 
to the alert physician. Chiefest among the indications are a dry, harsh skin, 
anaemia, pallor, oedema of face or extremities, any appearance or history of 
weakness, nervous exhaustion, over- work, irritability of temper, loss of virility, 
frequent headaches, disordered vision, excessive thirst, excessive or scanty 
uresis. For practical purposes, where there is no marked indication of disease, 
it will be sufficient to take the specific gravity and apply the albumin test of 
heat and nitric acid, which can be done in five minutes' time, with very little 
inconvenience and no expense. If specific gravity is found to be too high, or 
there is cloudiness in the albumin test, apply other tests, and secure another 
specimen of urine ; before testing for albumin, if urine is not of acid reaction, 
render it so by the addition of a few drops of acetic acid. The Examiner is 
expected to use the test with which he is most familiar ; but in addition to the 
well-known tests of Trommer, Fehling, Haines, etc., you will find Neidlander's 
Bismuth test a very pretty one, though not so delicate. Prepare as follows : 
Subnit. bismuth, 30 grains ; Soda et potas. tartrate, 1 drachm ; Liq. potas. 
[U. S. P.], 3 ounces. Mix and filter. Boil thoroughly a small quantity of the 
urine with equal part of the solution, and if sugar be present the mixture will 
turn a dark brown or black color. 

SUBJECTS DEMANDING SPECIAL CARE, INQUIRY AND EXPLANATION. 

Where the applicant's occupation is considered hazardous. 

Where there has been a rapid increase of weight, or a recent decrease. 

Where the abdominal measurement is greater than that of the thorax, or 
where the applicant cannot easily get two inches chest expansion. 

When the family history shows hereditary diseases of any kind. 

When the applicant has had any severe or recent illness, or when there is 
a history of general debility or nervous prostration. 

In cases where the applicant presents any deformity or has undergone any 
surgical operation. 

Where an applicant has ever had syphilis or stricture. 

Those who have had asthma, or who are subject to malaria. 

Where the applicant has a rapid pulse, especially if he has ever had rheu- 
matism. 



NORTHWESTERN MASONIC AID ASSOCIATION. 



\C)() 



In cases where the applicant receives a pension. 

Where the applicant habitually or daily uses malt or spirituous liquors, or 
those who occasionally spree, although they say they do not use it to excess. 

And such other points as are suggested by applicant's appearance, and 
family and personal history that would, in your professional judgment, aid us 
in passing on the risk. 



Table of Heights and Weights. 



HEIGHT. 












AVERAGE 
WEIGHT. 


30 PER CENT. 
ADDED. 


20 PER. CENT. 
REDUCTION. 






Feet. 


Inches. 








5 


3 


I 3 


169 


I04 


5 


4 


135 


175 


I08 


5 


5 


I40 


182 


112 


5 


6 


143 


186 


114 


5 


7 


145 


188 


Il6 


5 


8 


I50 


195 


I20 


5 


9 


155 


20I 


124 


5 


IO 


l6o 


208 


128 


5 


ii 


I6 5 


214 


132 


6 




I70 


221 


136 


6 


i 


175 


227 


I40 



The Following Table Shows the Expectation of Life 
for the Different Ages. 





1 

EXPECTATION 




EXPECTATION 




EXPECTATION 


AGE. 




AGE. 




AGE. 






OF LIFE. 




OF LIFE. 




OF LIFE. 


IO 




38 


29.62 


57 


16.05 


20 


42.20 


39 


28.90 


58 


15-39 


21 


41-53 


40 


28.18 


59 


14.74 


22 


40.85 


41 


27-45 


60 


14.09 


23 


40.17 


42 


26.72 


61 


13-47 


24 


39-49 


43 


25-99 


62 


12.86 


25 


38.81 


44 


25.27 


63 


12.26 


26 


38.11 


45 


24-54 


64 


11.68 


27 


37-43 


46 


23.80 


65 


II. 10 


28 


36.73 


47 


23.08 


66 


10.54 


29 


36-03 


48 


22.36 


67 


10.00 


30 


35-33 


49 


21.63 


68 


9.48 


31 


3462 


5o 


20.91 


69 


8.98 


32 


33-92 


51 


20.20 


7o 


8.48 


33 


33-21 


52 


19.49 


7i 


8.00 


34 


32-50 


53 


18.79 


72 


7-54 


35 


31-78 


54 


18.09 


73 


7.10 


36 


3 l -°7 


55 


17.40 


74 


6.68 


37 


3o.35 


56 


16.72 


75 


6.28 



I/O HOW TO EXAMINE FOR LIFE INSURANCE. 

SAMPLE COPY OF MEDICAL EXAMINER'S CONFIDENTIAL REPORT. 

On the examination of made at State 

of 

i. Has applicant any predisposition to hereditary disease ? 

2. Has he any predisposition to acquire disease ? 

3. Is his heart's action perfectly normal ? 

4. Does his pulse intermit or become irregular ? 

5. Are his lungs sound and healthy ? 

6. Is there any evidence of asthmatic or bronchial difficulty or tendency 
thereto ? 

7. Is there any evidence or suspicion of Bright's disease, cystitis or 
diabetes ? 

8. Does he show evil effects of habits ? 

9. Have you ever heard or suspected that he was at any time intemperate ? 

10. Is he too lean or too fat ? 

11. Is there any appearance or history of disease of brain or nervous system ? 

12. Does he appear older than he is ? 

13. Are his chances of long life, in your opinion, first-class, fair or doubtful ? 

14. On your professional honor, and in the interest of the Association, do 
you recommend him for membership ? 

Specific Gravity, Acid or Alkaline, Albumin, Sugar, 

Sign Medical Examiner. 

Graduate of Medical College, 18 

Date of this examination • 188 

NORTHWESTERN MASONIC AID ASSOCIATION. 

To M. D., Dr. 

To above examination, $ 



NORTHWESTERN MUTUAL LIFE INSURANCE 

COMPANY. 

INSTRUCTIONS TO THE MEDICAL EXAMINERS. 

The success of a Life Insurance Company depends largely on the ability, 
integrity and faithfulness of its Medical Examiners. Much reliance must, of 
necessity, be placed on their statements and judgment. 

The same professional pride and integrity which actuates the practitioner of 
medicine in performing his duty to his patient, should be displayed in his exami- 
nation of an applicant for Life Insurance. He can with no more impunity 
hazard his reputation as an Examiner for Life Insurance, by careless and 
indifferent examinations, than he can, by the same means, arrive at a false 
diagnosis and prognosis in the case of a private patient. Consequences of the 
latter mistake are well known to the profession, and by reason of the system 
of interchange of the causes of rejection of applicants by Life Insurance Com- 
panies, the former will prove equally as disastrous to his reputation. 

The relation of the physician to his patient differs from that of the Examiner 
to the applicant for Life Insurance. As a rule, the patient will voluntarily 
expose and perhaps magnify his infirmities, while with the applicant for Life 
Insurance the tendency is to lessen their importance or suppress their existence. 

A conscientious and faithful Examiner will be on the alert to detect any 
deception on the part of an applicant. 

He will not record an answer to a question until he is fully satisfied that the 
answer given by the applicant is a full, fair, and true answer to the question. 

Such an Examiner will, under no circumstances, permit personal friendship 
for the applicant or Agent to influence him in giving the Company a fair and can- 
did opinion as to the desirability or undesirability of each subject he examines. 

GENERAL REMARKS. 

In accepting the position of Medical Examiner for this Company, we trust 
you will appreciate the responsibility of such office. You are the guardian of 
the Company's interests in the locality for which you are appointed, and should 
endeavor to do all in your power to aid the Medical Department in its desire 
to accept only healthy and otherwise desirable subjects, bearing in mind the 
important fact that insurance tables are based on healthy lives. None other, 
under any circumstances, should be recommended for insurance. 

In forming an opinion as to the desirability of a risk, it is not only necessary 
to know that the applicant is free from disease, but that he is also free from 
any tendency thereto. His family and personal history are important factors, 
and form the basis for an opinion by the Medical Directors, as to whether a 
policy should or should not be granted. Hence the importance of a full, com- 
plete and impartial report bearing on these points. 

Your examination should be thorough, no matter how well you may know 
the applicant, or how vigorous he may appear. You should exercise great 

171 



172 HOW TO EXAMINE FOR LIFE INSURANCE. 

care in the exploration of the thorax. In all cases insist upon the chest being 
bared, or at least covered only by the undergarment. 

It is presumed at this office that when a subject is recommended, you have 
determined, to your entire satisfaction, by whatever additional means you may 
deem necessary to employ, that the applicant is free from disease and its effects. 
You should, after you have completed the application and your examination, 
but before you dismiss the applicant, read over the answers to the questions 
carefully, and for the time being commission yourself Medical Director of the 
Company, assuming for the moment you know absolutely nothing of the appli- 
cant or his family, except the knowledge derived from the statements made in 
the application and your examination. 

Would that knowledge be sufficient to enable you to pass intelligently on 
the risk ? If not, what further information would you require ? By supplying 
that information by further questioning the applicant (who is still within your 
reach), you will enable the Medical Director of the Company to act promptly, 
save correspondence, delay and annoyance to yourself, the applicant and all 
concerned. 

Apart from the results of your technical examination, what general impres- 
sion does the applicant make upon your professional eye ? If unfavorable, 
you should explain the impression under " Additional Remarks," and if of suf- 
ficient import, you should decline the risk, even though you can find no definite 
flaw in the applicant to account for it, remembering you alone have the appli- 
cant before you, and that the Medical Director of the Company has nothing to 
guide him except what is stated on the application, or by letter. 

In all doubtful cases, the Company should invariably be given the benefit of 
the doubt. 

FAMILY HEALTH RECORD. 

i. In many instances you will find the applicant unable to give the specific 
cause of death of some member or members of his family, but you can by 
judicious questioning as to symptoms determine in most cases the true cause of 
death, or at least that the disease was or was not organic in its nature. 

2. Death from the following causes, occurring in the parents, brothers, sisters, 
uncles, aunts and grandparents of the applicant, have an important bearing on 
the case, and should invariably be recorded, viz., Consumption, scrofula, epi- 
lepsy, insanity, brain diseases, gout, rheumatism, cancer, syphilis, etc. 

3. If an uncle or aunt has died of any of the above-named diseases, be 
particular to state whether on the paternal or maternal side. When a member 
of the applicant's family has died of some obscure disease, be particular to draw 
out the fact as to whether phthisis was or was not an element of the disease. 

4. In recording length of time sick, no idea is given as to the real cause of 
death by simply stating how long the party was confined to bed, but the length 
of time the syinptoms of the fatal illness were present should be stated. 

5. In many instances it will be necessary for you to postpone an examination 
to enable the applicant to ascertain the true cause of death of members of his 
family. 

6. It is desired to have the family record complete in all cases, but it is 
especially important in subjects under thirty years of age. 



NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY. 173 

PERSONAL HEALTH RECORD. 

I. Occupation and Residence. — Is the risk affected by anything in his 

dence or occupation ? 

II. Appearance, — Is there anything unfavorable in his general appearance? 
Any evidence of too free use of stimulants or of former sickness, or cachexia 
indicating disease of any kind ? 

III. Eruption. — Does the skin show any evidence of former syphilis, any 
sores, ulcers, or skin eruption present, or indication of disease of the bones ? 

IV. Otorrhea or Otitis. — Any history of otitis or otorrhcea ? If so, has he 
any discharge at present, or has he ever had ? 

V. Hemoptysis. — The history of an attack of hemoptysis should be fully 
explained. It should not be looked upon as accidental, unless coincident with 
some injury inflicted, or some violent physiceil effort made at the time it occurred. 
The statement that it came from the throat or gums should be fully proved to 
the satisfaction of the Examiner before the risk is approved. 

VI. Urinary Organs. — Symptoms of disease of the urinary organs, such as 
catarrh of the bladder, stricture, enlargement of the prostate, calculus, gonor- 
rhoea and frequent or excessive micturition, should be fully investigated. 

VII. Colic. — State whether hepatic, renal or intestinal. 

VIII. Rheumatism. — Any history of acute articular rheumatism ? If so, be 
particular to state the number of attacks, in what years they occurred, their 
severity, parts affected, etc. With such a history a most careful examination 
of the heart must be made. Two attacks, if the last one was recent, render 
the risk doubtful. 

IX. Ampliation. — State whether the amputation was from disease or injury. 
If from disease, be particular to state its nature. If of lower extremities, state 
what portion was removed, and whether the party is able to wear an artificial 
limb. 

X. Vaccination. — Be particular to search for evidence of successful vaccina- 
tion. Lack of same imposes a special clause in the policy contract reading as 
follows : — 

" It is provided and agreed that the within named is not insured by 

this policy against death by smallpox or varioloid, or in consequence of having 
had either, unless a certificate from one of the approved Medical Examiners 
of the Company, satisfactory to the Company, shall be furnished at its Home 
Office, that the person whose life is hereby insured has been successfully vac- 
cinated ; in which case the Company will assume the risk of death by small- 
pox or varioloid." 

XI. Urine — Examination of. — The urine should be voided in your presence 
to enable you to know positively that the specimen examined is that of the 
applicant. You should test for sugar and albumin in every sample you exam- 
ine, no matter what the specific gravity may be. If in previous examinations 
either has been found, if only a trace, this fact should appear on the application. 

AGE. 

It is contrary to the rules of the Company to date an application back for 
the purpose of giving the applicant the benefit of the premium rate for a year 
younger than the actual age. It would be unjust to the other members, apart 



174 HOW TO EXAMINE FOR LIFE INSURANCE. 

from its untruth, and in violation of the provision of the charter of the Com- 
pany requiring uniformity in premium rates, and must never be done under any 
circumstances. 

To illustrate : The applicant's age is 40 years, 6 months and 3 days. By the 
rule of the Company he would he required to pay the premium for age 41, 
which, on a twenty-payment life policy for $10,000, is annually $400 70 

By dating the application back three days, he would secure the insurance at age 

40, at an annual premium rate of . 389 20 

Difference annually $11 50 

The difference, with compound interest, in twenty years would amount to 
between $450 and $500. 

This gain is at the expense of the other members who pay their full pre- 
miums. 

Medical examinations made by a near7'elative, or one who has any pecuniary 
interest, directly or indirectly, in the policy, are not accepted. "Near relative'" 
includes cousins and others of closer blood relationship. 

GENERAL RULES GOVERNING EXAMINATIONS. 

1. Date. — You must invariably date your examination on the day it is made. 
If for any reason you are unable to complete it at once, state the cause of the 
delay under "Additional Remarks." 

2. Examine in Private. — The examination and that portion of the applica- 
tion written by you must be filled out in private, with no one present except 
yourself and the applicant. 

3. Attestatiofi. — The answers in the application should be free from altera- 
tion, interlineation and erasure. When unavoidable, the same must be 
attested by the applicant 's initials. Likewise corrected or changed answers in 
the examination must be attested by you. No one except the applicant has the 
legal right to change any of the answers over his signature. 

4. Identification — You are held responsible for the identification of the appli- 
cant. — You should refuse to make an examination, unless the applicant is per- 
sonally known to you or satisfactorily introduced. The same rule applies to 
persons presented for examination for certificate of health for the restoration 
of a lapsed policy, which in all cases must be paid for by the applicant. 

5. Family History. — In giving the cause of death, elicit the specific disease. 
Such terms as "exposure," "effects of cold," "childbirth," "change of life," 
"fever," etc., will not be accepted by the Company without an explanation. 

When members of the applicant's family are said to be in " fair" or " poor" 
health, the application must show the cause of the ill-health. 

In all uncertain causes of death, the report should, if possible, state whether 
phthisis was or was not an element of the fatal illness. 

6. Personal History. — Each question in number 15 must be read over sepa- 
rately by the Examiner and answered by the applicant "yes" or "no." It 
often happens that haemoptysis, fistula, and various other ailments there 
enumerated, are forgotten by candidates unless specifically inquired about. 
Question 23 must be answered explicitly, showing when he last consulted a 



NORTHWESTERN MUTUAL LIFE [NSURANCE COMPANY. 1^5 

physician, and for what. "I have never been seriously sick," or "Not con- 
sulted one for a long time," and the like, do not properly answer the question 
and camwt be accepted. 

7. Habits. — Be particular to draw out all the facts in regard to the present 
and past habits of the applicant as to his use of stimulants. If he has over- 
indulged, have him state over his own signature to what extent he has been 
intemperate, and when last under the influence of stimulants. If abstemious, 
have him state how long he has been a total abstainer. TJie answers on this 
poitit must be definite and co?ivey a clear idea as to the past and present habits 
of the applicant. 

8. Measure and Weight. — You should measure the applicant in every case, 
including shoes ; light weights and heavy weights should be accurately weighed, 
including their ordinary clothing. In either case state whether the overweight 
or underweight is or is not a characteristic of the father or mother, or both ? 

9. Adverse Opinion. — Whenever you postpone or do not recommend a risk, 
or should you give an adverse opinion on a risk, or decline to examine the 
applicant because of foreknowledge of his ineligibility, you are required to 
communicate the fact at once to the Medical Department at the Home Office, 
on proper blanks furnished by the Company, or by letter. 

10. Postpone. — You should postpone the acceptance of a risk who has 
recently suffered from a severe attack of illness until sufficient time has elapsed 
to insure perfect restoration to health. 

11. Confidential Information. — If for any reason you should prefer not to 
state in the application certain facts disclosed by the examination, you should 
at once write a confidential letter to the Medical Department, giving in detail 
such facts. Nothing affecting a risk should ever be withheld from the Home 
Office. Correspondence with respect to an applicant is always considered con- 
fidential. 

FEES OF MEDICAL EXAMINERS. 

1. A fee of five dollars will be allowed in all cases where a test of the 
applicant's urine is required (viz., applications of $2000 or over, and when the 
applicant is over 45 years of age). 

This fee is allowed whether the applicant is recommended for insurance or 
not, and will be paid by the Agent, and should be receipted for on the Com- 
pany's blanks. 

2. An additional fee of five dollars will be allowed for the microscopical 
examination of the urine, provided a request for such examination has been 
made by the Medical Department of the Home Office. 

3. But one fee will be allowed for any number of examinations of the same 
applicant made within thirty days. 

4. Only the regular fee for examinations will be paid. Extra charges, as 
for transportation or going unusual distances, must not be charged to the 
Company. 

5. The Examiner should present his bill at the end of the current month, 
plainly and legibly made out on the Company's blanks, with but one name on 
a line and properly dated. 

6. When Examiners are partners in business, each one must send bills for 
his personal examinations. No firm signature can be accepted. 



I76 HOW TO EXAMINE FOR LIFE INSURANCE. 

APPOINTMENT AND REMOVAL. 

Medical Examiners are appointed by the Medical Directors of the Com- 
pany, and are accountable only to the executive officers at the Home Office. 

They will not be removed except for cause. Among others, the following 
will be deemed sufficient cause for dismissal : — 

1. Failure to date the examination the day it is made. 

2. Failure to make the examination in private. 

3. Failure to notify the Medical Department promptly when an adverse 
opinion has been given, as per instruction 9 above. 

4. A lack of adequate professional skill and experience, independence, 
responsibility, and a courteous readiness to respond to calls to make exami- 
nations. 



THE PENN MUTUAL LIFE INSURANCE 
COMPANY. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

The Medical blank, for examination, used by this Company, differs in many 
respects from those that you have been accustomed to use, and we desire to 
call your attention to this matter in order that the modification will give us all 
as little trouble as possible. 

The Medical Examiner will read the questions to the applicant, and write 
the answers as given. The applicant will sign this, and it will form part of his 
application for insurance, or, in other words, his contract with the Company. 

In filling up these questions please write distinctly, give full particulars in as 
condensed a form as will be possible for a full understanding of the case. 
Should any additional remarks from you concerning the case seem needful, 
write them on that portion of the sheet which is exclusively for the. use of the 
Medical Examiner. Do not, under any circumstances, give your opinion of 
the case upon any of the paper above the applicant's signature. That part 
is a legal co7itract a7id is e7itirely his. 

Complete your paper as soon as you have finished the examination of the 
applicant, read it over carefully so that no questions may be unanswered, show 
it to no one, but mail it directly to the Medical Director. Should you deem it 
advisable to give more information than you can place upon the Medical blank, 
write it out in full on a letter sheet and send it with the paper. 

Your correspondence will be confidential, and it will give us pleasure to 
support you as the representative of the Medical Department of this Company 
at all times, provided you, in return, will do your utmost to aid us in selecting 
risks of a desirable character, whose habits and occupations and social sur- 
roundings will give them every prospect of completing their expectation of life. 

Always express your candid opinion as to whether or not we should accept 
the risk, at the same time bearing in mind that there are certain matters which 
are to be left to the judgment of the Home Office, such as questions of over- 
weight, or underweight, occupation, moral hazard, family record, etc. In such 
doubtful cases we wish from you all facts that will aid us in reaching an early 
decision. 

Our business is an increasing one, and we have, of course, to manage it upon 
business principles ; therefore, we hope that you will endeavor to follow out 
such instructions as have been formulated in order to expedite our work; and 
that you will endeavor, also, to aid our Agents in every way, knowing that indi- 
viduals are not always easy to convince as to the importance of insuring and 
may change their minds unless treated courteously and examined at once. 

Policies will be written on approved applications upon the lives of men for 
the following amounts : — 

Under age 21, not over, $ 5,000 

Between ages 21 and 24 (inclusive), up to, 15,000 

12 l?7 



I78 HOW TO EXAMINE FOR LIFE INSURANCE. - 

Between ages 25 and 29 (inclusive), up to, $20,000 

" " 30 " 55 " " 30,000 

" " 56 " 60 " " 20,000 

(Of which $5000 is to be Endowment Insurance, maturing not later 
than age 70.) 

Between ages 61 and 63 (inclusive), up to, 10,000 

Over age 63, not over, 5,ooo 

All persons accepted under the age of twenty-one years will be charged the 
rate for that age. 

The age is calculated from the nearest birthday. 

The limit for various ages upon such f 'ema le risks as may be acceptable (the 
rates being the same as those charged men) is as follows : — 

Age 18-21, #2,500 

" 21-30, inclusive, 5,000 

" 31-50, " 10,000 

" 51—55, " 20,000 

" 56-60, " 15,000 

" over 60, 5,000 

The following women are not insurable : — 

1. Those under 18 years of age. 

2. Married women until the birth of a child, or until 5 years after marriage. 

3. Pregnant women. 

4. Women nursing their children. 

Women Medical Examiners will be appointed in all cities as rapidly as con- 
sistent with proper selection by our Medical Director, also in any town where 
sufficient interest in the insurance of women is developed. 

Extra Premiums. — The following are annual extra rates per thousand dol- 
lars of insurance charged upon occupations considered more than ordinarily 
hazardous, viz. : — 

Stationary Engineers and Iron Ore Miners, $ 2.50 

Express Agents and Baggage Masters on Railroads, . . . 5.00 

Masters, Mates and Clerks on Lakes, Rivers and at Sea in Temperate 

Latitudes, and Engineers on Steamers, 5.00 

Engineers on Railroads, 10.00 

Mail Agents, 5.0Q 

No extra premiums for climate risk is charged officers of the United States 
Army and Navy. An extra premium, not exceeding three per cent., will be 
charged in time of war, which amount, if not paid in advance, does not 
invalidate the policy, but becomes a lien thereon. 

No risk will be taken upon women unless there is insurable interest in the 
life. 

The following classes are considered as uninsurable, viz. : gamblers, saloon- 
keepers, bartenders, hotel proprietors who attend bars, those personally en- 
gaged in retailing or in the manufacture of alcoholic stimulants, coal miners, 
firemen on locomotives, freight conductors, freight brakemen or those engaged 
in switching or coupling cars, manufacturers or handlers of explosives, divers 
or submarine workers, balloonists. 



THE PENN MUTUAL LIFE INSURANCE COMPANY. 179 

The following rules have been adopted to guide the Medical 
Examiners, and it is requested that they will be carefully read, 
in order to avoid a lengthy correspondence with the Home 
Office and a delay in the issue of the policy. 

1. You will please examine the applicant at your earliest convenience after 
receiving the signed application from the Agent, and mail your paper to the 
Home Office without delay. Should you desire to postpone the completion of 
your paper, inform the Medical Director at once of the delay and its cause. 

2. We require all our examinations to be strictly private ; no person to be 
present but the Examiner and the applicant. The questions on the first half of 
the examination blank are to be written by the doctor (at the instance of the 
applicant, who warrants their correctness and offers them as a consideration of 
the contract). The Examiner must not be a near relative of the applicant nor 
of the Agent. He must not be the beneficiary nor in any way pecuniarily 
interested in the policy. 

3. When the examination is completed, the application, having been read 
by the Examiner, is to be returned to the Agent, and the Examiner s report is 
not to be shown to any one, but is to be mailed by the Examiner to the Medical 
Director at the Home Office. 

4. Make all necessary inquiries that suggest themselves to you in reference 
to family history, previous diseases and habits, especially in regard to the use of 
alcoholic stimulants in the past and at present, a note of which you will please 
make in your paper. Much delay and unnecessary correspondence frequently 
results from hastily written papers, especially when the cause of death of near 
relatives is given as "childbirth," "pneumonia," "exposure," etc.; or when 
the applicant in his personal history alludes to attacks of "severe bronchitis," 
"nervous prostration," " neuralgia," — matters which may be of no importance, 
or again, may seriously affect the expectation of life of the individual. 

The Medical Examiner will please note these carefully, and if necessary 
obtain an explanatory statement, attested by the applicant, which will save 
time and trouble. 

5. Please also see that the applicant has been successfully vaccinated; 
examine for evidences of hernia in cases that are supposed to be cured, or if a 
rupture exists, see that a properly fitting truss is worn. 

6. In all cases for policies of over one thousand dollars ($1000) the urine is to 
be examined by heat and nitric acid for albumin and the specific gravity taken, 
and the Examiner should in each case satisfy himself that the urine he examines 
is that passed by the applicant. For this, including the ordinary examination 
of the applicant, the fee will be $5.00. The specific gravity is required in all 
cases. For $1000 and less, or where the total amount of insurance carried in 
this Company does not exceed $1000, no urine test is required unless the 
Examiner thinks it necessary. For these cases the fee will be $3.00. 

In all cases of insurance reaching five thousand dollars ($5000) and up- 
ward, the additional test of the urine for sugar (either Fehling's or Trommer's) 
will be required without additional fee. In all cases of less than $5000 should 
the Examiner (owing to high specific gravity, gouty diathesis, phthisis, or dia- 
betes in the family history) suspect sugar, he is expected to test for it, and note 



l8o HOW TO EXAMINE FOR LIFE INSURANCE. 

the result upon his examination paper ; when the specific gravity is below nor- 
mal, the Examiner will make several tests for albumin and report the results 
of each. 

7. Medical Examiners will please fill out the memorandum attached to each 
examination blank, without receipting it, and after a number of examinations 
have been made, checks will be sent from the Home Office in settlement of the 
accounts. 

8. The Medical Department is only authorized to pay the ordinary fees as 
mentioned above and an extra fee for a microscopic examination of the urine 
when ordered by the Home Office. No extra or traveling expenses are paid 
unless specially authorized by the Home Office. 

9. Please measure the applicant, in every case. Overweights and under- 
weights should always be accurately weighed by the Examiner. 

10. It is especially requested that the Examiner will read over the examina- 
tion paper after it is completed by him, before he mails it to the Home Office, 
as accidental omissions of important matters cause correspondence and delay. 

11. The ordinary examination of an applicant holds good for thirty days, 
after which a medical certificate of health is required before a policy is issued. 
Health certificates are paid for by the applicant. 

12. The medical portion of the examination blank contains only those ques- 
tions which are presumed to be sufficiently important to place the Examiner in 
a position to detect any disease, or disorder, which would affect the longevity 
of the applicant. They can be but suggestive, and it is presumed that when a 
risk is recommended the Examiner has determined, to his entire satisfaction, 
by whatever additional means he has deemed it necessary to employ, that the 
applicant is free from disease or the effects thereof 

13. The selection and appointment of Medical Examiners is made directly 
by the Medical Director. We desire to have two active Medical Examiners in 
each place where we do business ; the one to take the place of the other in case 
of absence, and both to act when more than $10,000 insurance is applied for 
(in which case two examinations are required). 

We have instructed the agents of the Company that, if they find themselves 
at a place in which we have not before done business, and where we have no 
regularly appointed Examiner, they can employ such physician to make exami- 
nations for us, who has been recommended in writing by our nearest Examiner; 
provided, that they cannot communicate with the Home Office. Any Examiner 
called upon to make such a selection, will please bear in mind that the interests 
of the Company are at stake, and that we wish only educated and reliable 
Examiners. It is requested of any Medical Examiner of the Company that 
when called upon by any Agent for a written or telegraphic recommendation of 
a physician to act as Examiner, he will only suggest the name of one who is 
either personally known to him, and in every way well qualified for the posi- 
tion, or one whose reputation for sobriety , honesty , and ?nedical attainment is 
beyond dispute. 



PHCENIX MUTUAL LIFE INSURANCE COMPANY. 

INSTRUCTIONS TO THE MEDICAL EXAMINERS. 

Your most careful consideration is requested to the following remarks and 
suggestions: — 

An application for a policy of life insurance is framed with a view of showing 
two points respecting the applicant : First, whether there is anything in con- 
nection with his physical condition which will militate against longevity; and, 
second, whether any circumstances connected with his family history will be 
likely to affect unfavorably his constitution and strength. 

It is exceedingly important that the Examiner shall consider these points 
together. The figure, in connection with the family history, will frequently be 
of vital importance in determining the desirability of the risk. It is therefore 
desired that the Examiner shall read the questions which are put to the appli- 
cant, and the answers which he makes, before entering upon the examination 
of his person. He will in this way, before he makes his examination, become 
familiar with the condition, occupation and family history, and can make his 
examination accordingly, paying attention to such points as may be necessary. 
There has been placed in the application an expectation table, for the purpose 
of calling your attention to the length of time which the insured must live to 
enable the Company to successfully conduct its business. It is expected that 
any person to whom a policy is granted will live at least the number of years 
indicated by this table, and if for any reason the probabilities are against this, 
the Company does not desire to issue a policy. It is desired and expected that 
the Medical Examiner will be wholly independent of the Agent, for unless his 
opinion can be given without bias, it cannot be one upon which we can rely, 
nor its value what we expect. It will therefore be esteemed a favor if any 
Examiner wall communicate directly with the Company on any point concerning 
which he does not wish for any reason to enlarge in the application itself. We 
shall always be glad to correspond with you about any matters concerning 
which you desire information or advice, and ask for your candid opinion in 
each case which may come before you. 

An inspection of our losses has shown that the use of liquor causes, either 
directly or indirectly, many deaths, and this is a point about which we wish to 
be informed particularly, so far as your observations go. If the applicant is 
knowm to you to be addicted to any pernicious habit, we desire to be informed 
directly by you, and all such information which we may receive may b'e 
regarded as strictly confidential. It will be well to bear in mind that the 
mortality among the members of any Company cannot be excessive and that 
Company live and prosper. No care in the management in other respects can 
make up for a lack of prudence in the selection of members. The future wel- 
fare of the Company is thus largely dependent on your skill and judgment, and 
it is entitled to your best and most careful opinion, which shall lean to the side 
of caution in cases of doubt. 

iSl 



1 82 HOW TO EXAMINE FOR LIFE INSURANCE. 

In deciding at the Home Office upon the acceptance of applications for Life 
Insurance sent from agencies, great reliance must necessarily be placed upon 
your statements and opinions. You are justly considered, in an important 
sense, the guardians of the Company's interests. Upon your skill in the 
examination of subjects for insurance, and the fidelity of your reports, depend 
in no small degree its success and safety. 

While the following remarks are intended to prescribe to a certain extent 
your duties, they are also designed to be suggestive. For, with all the direct 
instructions which may be given, a very large margin must of necessity be left 
for your own judgment, and you must ever exercise that vigilance which it is 
impossible to define, in order to secure and protect the interests of the 
Company. 

You should always keep in mind the fact that there will be a strong ten- 
dency on the part of the unscrupulous to make false statements and to cover 
up everything which could impair the probability of acceptance. You will, 
therefore, be very careful to look out for and detect hidden disease, or condi- 
tions of the system calculated to shorten life, and observe particularly the 
effect upon the constitution of any previous disorder. 

Examinations should be considered confidential, as between yourself and 
the party, and no person should, as a general rule, be allowed to be present. 

Very often it may be best not to communicate the result of your investiga- 
tions to the party examined, but in this matter you must be governed by your 
own judgment. 

In making an examination, you will first ascertain the occupation of the 
party, its effects upon his health, the age, weight, height and general appear- 
ance. You will then direct particular attention to the following points : — 

1st. The family history, longevity of ancestors, and in regard to whether 
insanity, apoplexy, scrofula, epilepsy, phthisis, or renal disease has existed in 
the family. 

2d. Any illness during the life of the applicant, particularly spitting of 
blood, gout, rheumatism, asthma, smallpox, or vaccination, pulmonary com- 
plaints, fits, etc. 

3d. General habits of applicant's life in reference to the use of intoxicating 
drinks, opium, etc. 

4th. Observe particularly the character of the pulse and respiration. A 
very careful examination into the condition of the heart and lungs should be 
made. 

Place your hand upon the chest and see if you can detect any inequality in 
its formation, or in the respiration. 

Observe whether the chest be expanded, or narrow and depressed, especially 
in the subclavian region. Also if the " vesicular murmur" is clear and recog- 
nized in all parts of the lungs, and whether abnormal sounds can be detected. 
Do not allow any covering of the chest to interfere with a thorough and search- 
ing investigation into its capacity and the condition of the lungs. 

Be very careful to see if there be any tubercular deposits in the lungs. This 
is one of the most common diseases and in its incipient stage most apt to 
deceive the Examiner. Examine most critically the apex of the lungs, as it is 
there, as a general rule, that tubercles are first deposited. 



PHOENIX MUTUAL LIFE INSURANCE COMPANY. 1 83 

5th. If rheumatism has existed, examine carefully the conditions of the 
heart with reference to the effect of the disease on that organ. 

6th. If the applicant be slender in form, of light weight, pale, or of sallow 
complexion, be particular to ascertain whether these conditions are recent or if 
such is the usual state. 

7th. If there are indications of disease of the urinary organs, the urine 
should be tested, and its condition noted. State if it contains cither mucus, 
pus, blood, albumin, casts, cells or sugar ; whether alkaline or acid, specific 
gravity, color, and average amount passed daily. When the application for 
insurance, including insurance in this Company on the same life already in 
force, reaches the sum of $5000 or more, the Medical Examiner will report 
upon the condition of the urine, on the blank furnished by the Company. 

8th. If syphilis has existed, inquire as to its effect upon the system, and 
whether there has been any secondary effect. 

Examine as to whether there has ever been enlargement of the prostate 
gland, stricture or retention of urine. 

9th. Female applicants should be questioned as to number of children born, 
the character of the labor, and if it has been difficult, the effect upon the con- 
stitution. 

The result of your investigations on each of the foregoing points you will 
please state clearly on the certificate, together with any other statements or 
information that will aid the Company in arriving at a perfect understanding 
of the case. In some cases it may be advisable for you to state your opinions 
more fully than is covered by the certificate. Under these circumstances please 
communicate by letter. 

If the examination is not satisfactory in any of the vital points, recommend 
the non-acceptance of the risk. 

Again let us impress upon you the fact of your responsibility, and the 
dependence of the Company upon your skill and fidelity. Conduct your 
examinations with great care, and always consult and endeavor to protect the 
interests of the Company. 



PROVIDENT SAVING LIFE ASSURANCE 
SOCIETY. 

INSTRUCTIONS TO THE MEDICAL EXAMINERS. 

In the examination of a risk for life insurance, there are just three essential 
points to be borne in mind, viz. : (a) The family history ; (6) The personal his- 
tory ; (c) The present physical condition. 

(a) Family History— k first-class family record is of itself a strong recom- 
mendation to the applicant, and he should be duly credited therewith. On the 
other hand, a poor family history detracts from the chances of the risk by 
exhibiting certain predispositions to disease on the part of the applicant. 
Whenever requested by the applicant to hold his medical history private, 
deliver a sealed report to the Agent, with request that the same be mailed, 
unopened, to the Home Office. 

Rule I. — Always correct any loose or equivocal statements on the part of the 
solicitor in answer to "causes of death" of his relatives. Statements such as 
"old age," "natural death," "complication of diseases," "decline," "lung 
fever," "childbirth," "exposure," "don't know," etc., should not be accepted. 
If, through ignorance, no other answer can be offered, the Examiner should 
always put such questions as may lead to some history regarding the previous 
health, duration of sickness, nature of death, of the deceased, and then make 
notes accordingly upon the application. 

Rule II. — When both parents have died of phthisis, positively decline the risk. 
When one parent only has died of phthisis, and the applicant has not yet reached 
the age of 35, defer the risk ; if over 35, and family record and physical condi- 
tion be good, accept the risk, leaving a final decision to the Home Office. 

It has erroneously been stated that the liability to pulmonary consumption 
diminishes remarkably after the age of 35 ; while the truth is, "the proportionate 
mortality from that disease does not vary between the ages of 1 5 and 70 as much 
as is generally assumed." Dr. Sieveking, from whom we have just quoted, 
further says : " And we would warn the medical officer against yielding to the 
popular impression that this inquiry becomes unnecessary after full manhood is 
reached, as the danger of phthisis continues beyond the age of 60 ; an impression 
that weighs much with boards of directors, who will admit evidence of a con- 
sumptive taint from puberty to 25, which they frequently put aside as insignifi- 
cant after that period." 

Rule III. — ib) Personal History. — Be sure that the person examined is the 
same whose name is attached to the application. Statistics and " tables of com- 
parison " have been made as standards for life insurance. These tables are 
appended to the Instructions, and your study of them in every examination is 
requested. 

Rule IV. — In the personal history of the applicant, pay especial attention to 
the following points, viz. : — 

{a) Occupation. — Publicans, stonecutters, grinders, bakers, printers, miners, 

185 



1 86 HOW TO EXAMINE FOR LIFE INSURANCE. 

painters, etc., are, as a rule, undesirable risks, particularly so where the physical 
status of the applicant is not first-class. 

(b) Personal Habits. — Question the applicant closely as to past and present 
indulgences in alcoholic liquors, beers, narcotics, etc., and impress upon him 
the necessity of giving specific answers to these questions in the application. 

(c) Height and Weight. — The percentage of variation between height and 
weight is obtained by dividing the difference between the normal and actual 
weight by the normal weight (see table). " When an applicant exceeds or falls 
below the average weight proportionate to his height, by 40 per cent, and 20 per 
cent, respectively, he transcends a safe limit." 

Excess of waist over chest at full inspiration is abnormal, and should cause 
the Examiner to consider fatty degeneration, apoplexy, abuse of alcohol, dia- 
betes, overweight, etc., etc. 

(d) Lungs. — Dr. Sieveking states that of the total mortality from all causes 
in England and Wales, one-ninth is due to pulmonary consumption. It behooves 
the Examiner, therefore, to be very thorough in his examination of the lungs. 

Rule V. — All measurements and examinations must be made under the vest. 
A chest capacity of less than 2}4, inches should reject. 

One of the earliest indications of pulmonary disease is a habitually quick 
pulse. The pulse in a normal adult man is about 70. Any pulse at or about 
85, which at the same time is weak and deficient in volume, must be looked 
upon with suspicion. In all cases where the rate exceeds 80 to the minute, 
another trial, when the applicant is off his guard, must be made. 

"A weight which is much below the average at or after 30, especially if 
accompanied by an accelerated pulse and breathing, undoubtedly justifies an 
increased rate, even if no other signs of a tainted constitution be found. Our 
experience of the policies that have become claims has forced the conviction 
upon us, that medical men and insurance offices would do well to regard these 
points more seriously than is generally done in estimating the expectation of 
life." — Sieveking. A true hoei7ioptysis invariably rejects. 

(e) Heart and Great Vessels. — Dr. Sieveking assigns to this class one-sixth 
of the total mortality from all causes, " a proportion that is much larger than 
appears to prevail in insurance offices." In this country, where there is a great 
prevalence of rheumatic fever, the proportion may not be regarded as too large, 
after all. 

The simplest and most practicable division of abnormal heart sounds for 
diagnosis in life insurance, we would arrange as follows, viz. : — 

1. We may exclude murmurs connected with the right side of the heart, 
because they are quite rare. 

2. Confining our attention, then, to the left side of the heart, we shall have 
four possible heart murmurs to keep before the mind and ear. 

(a) With the heart's systole, mitral regurgitant, or aortic obstructive murmur, 
or both together. 

(b) With the heart's diastole, aortic regurgitant, or mitral obstructive murmur, 
or both together. 

The seat of these sounds or murmurs will determine the location of the 
valvular lesions. 

Of all these valvular lesions, aortic regurgitant is the most significant. Dr. 



PROVIDENT SAVING LIFE ASSURANCE SOCIETY. 1 8/ 

Walshe writes : " I have known death take place during the act of walking, of 

eating, of speaking; while the patient was emotionally excited, and, per I ontra, 
at a moment when he was perfectly calm. And a very singular proposition is, 
that the more pure and uncomplicated the regurgitant, the freer the heart from 
any other form of disease, the more likely is the individual to be cut off without 
a moment's warning. There is no direct connection between the amount of 
danger of disease at an orifice of the heart and the intensity of an existing 
murmur; the very weakness of a murmur may, indeed, be a fatal sign.'' A 
history of recent inflammatory rheumatism will postpone for a year. 

An intermittent pulse is not of itself sufficient cause for rejection, as it is 
sometimes found in the healthy. But an irregular or remittent pulse must 
ever be taken with suspicion of some grave disorder, either in the heart and 
great blood vessels, or in the economy at large. It is sufficient alone to 
justify rejection. 

Rule VI.— (c) The Kidneys. — This Society requires the chemical examina- 
tion of the urine in all cases. The Society does not demand a refinement of 
tests. For albumin, " Heller's test," or the trickling of nitric acid down the 
side of the inclined tube containing urine, is at once the most accurate and 
practicable. If no ring or cloud appear against the acid below and urine above, 
it will be safe to say " no albumin." When the urine is turbid on being voided, 
filter before making this test. With an acid urine, boiling will reveal albumin. 

The only possible source of error in these two tests is the presence of an 
excess of urea or urates ; but here, in the one case, heat, and in the other, acid, 
will clear away all clouds of doubt. These two tests, together with the specific 
gravity, are all that is required by the Society. A specific gravity under 1015 
or over 1028 demands repeated tests in order to determine whether it is merely 
transitory or permanent. 

For sugar, "Trommer's test," or freshly-prepared " Fehling's solution," will 
be sufficient. All urine should be tested for sugar, regardless of the specific 
gravity. 

If a urine at or above 1030 gives no sugar on repeated tests, the Examiner 
may have reason to suspect an excess of urea, or that condition of the body 
known as azoturia, and he should look for some vital disturbance in the assimi- 
lative organs. 

Both albumin and sugar may appear in urine at times, and be indicative 
only of functional derangement, and not of organic disease. 

But this Society recognizes in these manifestations, even when slight, evi- 
dence of a departure from the healthy standard, and requires, in the case of 
albumin, a postponement of three months, and of sugar, a reexamination within 
a few days of a specimen of urine passed an hour after a full meal. 

A microscopical examination of the urine is only expected when the Exam- 
iner may feel suspicious of Bright's disease, not revealed by the chemical tests. 
An additional fee of two dollars will be allowed for this examination. 

As in phthisis, so in Bright's disease, the character of the pulse offers early 
indications of the disease. Dr. T. A. McBride, of New York, has contributed 
a very interesting paper on this subject. He believes that a pulse which is full, 
tense and non-compressible is indicative of high arterial pressure, and if per- 
manent, will sooner or later produce organic changes in the renal tissues. 



188 



HOW TO EXAMINE FOR LIFE INSURANCE. 



Medical Fee. — The fee for a medical examination in this Society is three 
dollars, whether the risk be accepted or rejected, and the Society holds itself 
responsible for the payment of the same. Accompanying these Instructions 
you will find suitable blanks for declined or deferred risks, which in all such 
cases are to be filled out by you, and sent, sealed, direct to the Medical De- 
partment. Please accompany this report with your bill, giving the name in 
full, residence and date of examination. 

The payment of your fee will depend upon compliance with this request. 

Kindly acknowledge the receipt of this book and oblige the Medical Depart- 
ment. 

Table of Height, Weight and Chest Expansion. 



HEIGHT. 


("VITAL CAPACI- 


STANDARD 


20 PER CENT. UN- 


40 PER CENT 


TY") CHEST. 


WEIGHT. 


DER WEIGHT. 


OVER WEIGHT. 


Ft. 


In. 


Inches. 


Pounds. 


Pounds. 


Pounds. 


5 


o 


33/2 


115 


92 


161 


5 


i 


34 


120 


96 


168 


5 


2 


35 


125 


IOO 


175 


5 


3 


36 


130 


104 


182 


5 


4 


3^/2 


135 


108 


189 


5 


5 


37 


140 


112 


196 


5 


6 


37 l A 


H3 


114 


200 


5 


7 


38 


145 


Il6 


203 


5 


8 


3*y 2 


148 


H9X 


208 


5 


9 


39 


155 


124 


217 


5 


io 


39'A 


160 


128 


224 


5 


ii 


40^ 


165 


132 


231 


6 


o 


41 


170 


136 


238 


6 


1 


41 y 


175 


I40 


245 



Expectation of Life Table. 

(According to the American Table of Mortality.) 





EXPECTATION 




EXPECTATION 




EXPECTATION 


AGE. 




AGE. 




AGE. 






OF LIFE. 




OF LIFE. 




OF LIFE. 


21 


41-53 


39 


28.90 


57 


16.05 


22 


40.85 


40 


28.18 


58 


15-39 


23 


4O.I7 


41 


27-45 


59 


I4.74 


24 


39-49 


42 


26.72 


60 


I4.O9 


25 


38.81 


43 


25-99 


61 


13-47 


26 


38.11 


44 


25.27 


62 


12.86 


27 


37-43 


45 


24-54 


63 


12.26 


28 


36.73 


46 


23.80 


64 


11.68 


29 


3603 


47 


23.08 


65 


11. 10 


30 


35-33 


48 


22.36 


66 


10.54 


31 


34.62 


49 


21.63 


67 


10.00 


32 


33-92 


5o 


20.91 


68 


9.48 


33 


33-21 


5i 


20.20 


69 


8.98 


34 


32.50 


52 


19.49 


7o 


8.48 


35 


31-78 


53 


18.79 






36 


31-07 


54 


18.09 






37 


3o.35 


55 


17.40 






3- 


29.62 


56 


16.72 







UNION CENTRAL LIFE INSURANCE COMPANY. 

INSTRUCTIONS TO AGENTS CONCERNING MEDICAL EXAMINERS. 

i. Before canvassing any locality for the first time, request the Home Office 
to send you a list of its Medical Examiners in that locality. 

2. If the Company has no Medical Examiner in the place where you expect 
to do business, request the best regular physician in that place to fill one of 
our blank applications for appointment as Medical Examiner and forward 
to us. 

3. All Medical Examiners are appointed by the Medical Department at the 
Home Office. 

4. We do not, as a rule, appoint more than two Medical Examiners in one 
locality. 

5. The regularly appointed Medical Examiners must be employed by Agents 
until otherwise instructed by the Medical Directer. 

6. We are glad to have our Medical Examiners insure with the Union 
Central, but do not require them to do so before they can be appointed. 
If they take policies with us they must pay their premiums to the Company 
the same as other policy holders do. 

7. We do not, under any circumstances, permit an Agent to take a policy 
on the life of a physician with the understanding that he will be appointed 
Medical Examiner, and that the examinations required in his neighborhood 
will be given him. 

8. If our regular Medical Examiners do not satisfactorily perform their duties 
our Agents can inform us, and furnish us a statement of their short-comings, 
and we will make an investigation, but until otherwise instructed by us, the 
regular Medical Examiners must be employed. 

9. If any of our Examiners remove from the locality they were appointed 
for, or become incapacitated by disease or age, or if any have contracted habits 
which will impair their usefulness or standing in the community, report the 
facts to us at once. 

10. We desire our Examiners to be physicians of wide experience, unques- 
tioned ability and undoubted character. 

INSTRUCTIONS TO MEDICAL EXAMINERS. 

In your examinations for us let your replies be in your own handwriting. 

Let it be distinctly understood that our table rates are for insurance on sound 
lives, and that none but strictly such are to be unqualifiedly recommended by 
the Examiner. 

Direct your inquiries specially to any family tendency to consumption in 
any form, in either the direct or collateral branches ; to insanity, apoplexy, 
cancer, scrofula, rheumatism, diseases of the heart, or syphilitic diseases. 

Ascertain whether the applicant is temperate and pure in his habits of life, 
and whether he has always been so, being careful not to recommend to the 

189 



I9O HOW TO EXAMINE FOR LIFE INSURANCE. 

Company any person of intemperate or lewd habits, or any reformed inebriate, 
and state clearly the facts as to his present habits and his antecedents in these 
respects. 

Often, in consequence of an indefinite or ambiguous answer by the Medical 
Examiner, in the family history or personal examination of an applicant, which 
a few words might explain, a correspondence is entailed which not only takes 
up the time of the Officers and Medical Examiner, but necessitates vexatious 
delays to both applicant and Agent, and frequently ends in the withdrawal of 
the party applying for insurance. In order to avoid these delays and expedite 
action, we respectfully request you to carefully and clearly answer all questions. 

If the health of any living relative is reported as "feeble" "moderate" or 
"poor" please explain why they are not in robust health, and state whether or 
not they have cough, consumption, or other constitutional disease. 

If the party be much under or over weight put him on the scales and weigh 
him, as well as measure his height. 

If the pulse is above 80, postpone final action until the party can be exam- 
ined under conditions favorable to quiet and composure. The pulse rate of 
most persons will be accelerated when first brought into the presence of a phy- 
sician for examination ; also after eating a hearty meal, and immediately after 
active exercise. If after sufficient time has been given for these influences to 
subside, the pulse still remains high, the fact must be reported. 

If the party be a woman over 40 years of age, always state whether or not 
she has successfully passed her climacteric period. 

If you report the appearance of a party as " moderately good" please ex- 
plain whether you mean that he is up to the average of selected lives or 
below it. 

Be particular in giving the ages and cause of death of grandparents, but 
if they cannot be ascertained, state, if possible, whether they " attained old 
age" or " died ea7'ly in life." 

We respectfully request you to read carefully, and to be guided by the direc- 
tions, contained in the following paragraph : — 

What is your family history, according to the following schedule ? $g^ In 
stating the cause of death, avoid such expressions as "general debility" 
"change of life" "fever" "exposure" or any other indefinite term. If the 
expression "childbirth" is used, be particular to state how long after the 
delivery of the child, and also whether there were any symptoms of chest 
trouble, viz. : cough, expectoration, loss of flesh, night-sweats, etc. If the 
health of any of your living relatives is stated as "moderate" or "fair," 
state in Remarks what ails the person. 

We depend on you as a Medical Expert to act in the interest of our Com- 
pany. With the interest of the Agent or applicant you can have nothing to do. 
You are employed by the Company. And in expressing an opinion adverse 
to the life of an applicant, we respect your judgment as highly, and pay you 
the same fee, as when you express a favorable opinion. 

You will readily perceive how important and responsible is the relation which 
the Examining Physician sustains to a Life Insurance Company ; upon the skill 
and vigilant scrutiny with which each individual examination is conducted the 
interest of the Company must necessarily depend. If each Examiner of a 



UNION CENTRAL LIFE [NSURANCE COMPANY. K)I 

Company passes one unsound life, the aggregate of such members would so 
diminish the average vitality of the whole as seriously to impair the permanent 
safety of the institution. We need, therefore, offer no apology for the urgency 
and minuteness with which we solicit your best efforts in the performance of 
this most responsible service. 

If you are aware of any facts bearing unfavorably upon the risk which you 
may not care to notice in the report, you can communicate them by letter to 
this office, and all such communications will be considered strictly confidential. 
Such communications should be written and mailed immediately after your 
examination, in order to reach us before action has been taken on the applica- 
tion. 



UNION MUTUAL LIFE INSURANCE COMPANY 

OF MAINE. 

TO AGENTS AND MEDICAL EXAMINERS. 

i. Examinations are to be made only by the duly appointed Examiners of 
the Company. 

2. When an Agent contemplates soliciting in any new field, he should at 
once write to the Company for the name of the Medical Examiner to be 
employed. The Agent should not wait until he has a party to be examined 
before attending to this, as the proper selection of the Examiner often requires 
a week or more ; and, as this rule is inflexible, too much importance cannot 
be given to attending to the appointment promptly. 

3. No time will be saved by having examinations made by Examiners 
unknown to the Company, as they will not be accepted, and the fee will have 
to be paid by the Agent employing them. 

4. The usual fee allowed by the Company to be paid for each examination 
is from S3 to $5. The latter is allowed only when urine is examined. Fees of 
the Medical Examiner will be paid, whether the applicant is accepted or 
rejected, provided the application has been received by the Company. 

5. The causes for rejecting applicants will not be disclosed, as they are, 
in a measure, confidentially communicated. 

6. Bills for examinations should be made out monthly, and mailed by the 
Examiner direct to the Company for payment. Agents are requested to instruct 
the Examiner to this effect, and furnish him with the bill-heads supplied by the 
Company, but in no case to pay such bills. 

7. All applications upon which an examination has been made must be 
sent to the Company, whether recommended by the local Medical Examiner 
or not, as a check upon the correctness of the Examiner's bills when presented. 

8. The Company should not be subjected to the expense of a medical 
examination, when the personal or family history of the applicant would 
render his rejection probable. 

9. Every applicant must be examined by the Examiner appointed for the 
place where the applicant resides; otherwise the Agent will have to pay the 
medical fee, and the applicant be reexamined. 

10. If, however, an application is taken at a considerable distance from the 
applicant's usual place of residence, an exception to this rule may sometimes 
be made, but only when clear and satisfactory evidence is furnished to the 
Company that the applicant could not be examined by the regular Examiner 
of this Company at the proper place; which evidence should, in all cases, be 
furnished at the time of forwarding the application. 

11. If an Agent should unexpectedly enter a new field and secure applications 
(not having had time to apply for an Examiner there), he may get these risks 
examined by the physician of one of the we I I- known Old Companies ; but, with 
the first application so taken, the Agent must forward to the Company a full 

13 193 



194 H0W T0 EXAMINE FOR LIFE INSURANCE. 

explanation, stating where and when the Examiner graduated, to whom he 
refers, and for what Company or Companies he is or has been the Examiner, 
on forms provided for that purpose. Only with this explanation will the new 
applications be entertained. 

12. As all Medical Examiners are selected and appointed through the 
Home Office, and solely on the ground of professional qualification, Agents are 
particularly cautioned against soliciting physicians for insurance by holding 
out the inducement of an appointment as Medical Examiner, or by making 
any promises to that effect, and it is better to avoid any complication which 
might result in injury to the Agent's business. (We speak of this, because it 
was formerly the custom to secure the application of physicians upon such 
promises ; but no Agent of this Company is now at liberty to make any such 
agreement.) 

13. After an appointment has been made in any given town, the Manager 
of the agency in Which the town is located will be notified, and he must 
inform his solicitors ; and, after the Manager is notified, the regulation laid 
down in No. 1 will be strictly adhered to. A list of the Examiners in every 
Manager's territory is furnished from the Home Office, and the names on this 
list should be transferred to a suitable book for reference, and the additional 
names that may be furnished from time to time, added as the appointments 
are made. This list and book must be left at the agency office, on the retire- 
ment of any Manager. 

14. It is greatly to the convenience of the Company to have Medical 
Examiner's accounts made out on the regular bill-heads prepared for that pur- 
pose, and Agents should carry some of these among their other canvassing docu- 
ments, and furnish one or more to the Examiner at the time of presenting 
applicants for examination, with the request that the Doctor forward his bill 
direct to the Home Office at the close of every jnonth, no matter how small the 
bill. 

15. The average fee for examination is $3, with an extra $2 when urin- 
alysis is required. Beyond this, Agents must not promise anything for travel- 
ing fees or other extras (indeed, the question of fee is usually settled with 
the Examiner at the time of his appointment, by the Home Office). Most 
Examiners will go a reasonable distance to examine applicants who cannot 
come to them, for the usual fee. 

16. We would call special notice to paragraph No. 7. Neglect to forward 
applications upon which examinations are recorded leads to correspondence 
and delay in settling medical bills. Therefore, all applications which have 
been through the examination, should be forwarded at once to the Home 
Office, as without these there is no means of ascertaining the correctness of 
medical bills. 

17. Paragraph 8 should be well kept in mind by Soliciting Agents. 
It is about useless to present for examination, parties who have had " blood- 
spitting,''' or recent or repeated attacks of i7ifla?nmatory rhemnatism, or whose 
family records exhibit a decided tendency to consmnption. A little intelligent 
questioning of the party before "writing him up," will develop the fact of 
uninsurableness, frequently, and save the Company the expense of examina- 
tion, and the applicant the mortification of rejection. In cases of reasonable 



UNION MUTUAL LIFE [NSURANCE COMPANY. 

doubt, it will be well to outline the case in the letter to the Medical Director, 
and ask for advice whether or not to have the party examined. 

There are excellent reasons for insisting on paragraph 9, which, if not 
quite clear at first, will become so after a little thought. 

18. Agents must remember that the Examiners selected by this Com- 
pany are the busy, practical medical gentlemen in the community (because 
these men are likely to be the best posted), therefore they are not always 
available for an examination at any moment, and it will be well for the Agent 
to endeavor to make his plans harmonize with those of the Examiner, as far 
as possible ; and, of course, on the other hand the Examiner ought to try to 
accommodate the Agent as much as he can Any real cause for complaint 
against ah Examiner will always receive attention, but Agents must not expect 
the Company to change its Examiners, except tipon strong necessity clearly 
shown. The fact that 07ie physician in a community will promise his aid to 
help the Agent, and will take a policy in the Company, while another docs not, 
will have no weight as reaso?i for a change. If the physician appointed does 
his work well, and is willing to do his best to make" the Agent's work go 
smoothly, this is all the Compa?iy can ask. We are obliged to be thus explicit, 
because Agents are constantly asking for changes of Examiners, upon grounds 
that are trivial and unreasonable. 

19. In soliciting, if parties are written up who are greatly out of propor- 
tion in their height and weight, they should be led to expect short endow- 
ments only ; for such subjects do not, as a rule, make profitable risks for life 
or long-term policies, and, by keeping this -in mind, many disappointments 
will be avoided. On another page will be found a table, giving the average 
weight for the height set opposite. Next to the column of average weight is 
one giving a twenty per cent, addition to the average, and still another column 
showing what would be the weight with twenty per cent, of the average deducted. 
Now, other things being equal, this variation of twenty per cent, from the 
average, either way, is generally considered compatible with good health ; but, 
if the departure go very much beyond these figures, it is prejudicial to the risk, 
and such cases would only be granted endowments according to the judgment 
of the Home Office, and, if too much out of proportion, declined altogether. 

20. Negroes are practically excluded as risks ; but short endowments may 
be written on exceptionally good cases. (Very careful inquiry should, how- 
ever, be made, and the Home Office consulted, before putting the Company 
to any expense for examination.) 

21. Policies will not be issued on Proprietors of Hotels, Keepers or 
Attendants of Restaurants, and Bar and Salooii Keepers, or persons engaged in 
the i7ianufac ture of Liquor, Ale, etc. 

22. An unmarried woman or a married woman who has never had a child 
will not be insured until she is over 48 years of age. 

23. The experience of all Life Insurance Companies shows that the classes 
named above are very hazardous ones upon which to write insurance. Hence 
the decision of this Company not to entertain them as applicants. 

24. It is always best that the Examining Physician and the applicant be left 
entirely to themselves during an examination. 

To insure prompt issuing of policies, special care should be taken to 



196 



HOW TO EXAMINE FOR LIFE INSURANCE. 
Table of Height, Weight and Measure. 









AMERI- 






AVER- 








CAN 










25 PER 


20 PER 


STAND- 
ARD 


25 PER 


40 PER 


AGE 


HEIGHT. 


CENT. 


CENT. 


CENT. 


CENT. 


CHEST 


UNDER 


UNDER 


OVER 


OVER 


MEAS- 








AVER- 










WEIGHT 


WEIGHT 


AGE 
WEIGHT 


WEIGHT 


WEIGHT 


URE- 
MENT. 


Ft. 


In. 


Pounds. 


Pounds. 


Pounds. 


Pounds. 


Pounds. 


In. 


5 




8$ 


92 


115 


144 


161 


33 


5 


1 


90 


96 


I20 


150 


168 


34 


5 


2 


94 


100 


125 


156 


175 


3S% 


5 


3 


97 


104 


I30 


163 


182 


36 


5 


4 


IOI 


108 


135 


169 


189 


36X 


5 


5 


105 


112 


I40 


175 


196 


37 


5 


6 


107 


114 


143 


178 


200 


31% 


5 


7 


109 


116 


145 


181 


203 


38 


5 


8 


III 


119 


I48 


185 


208 


3%y 2 


5 


9 


116 


124 


155 


194 


217 


39 


5 


10 


120 


128 


l6o 


200 


224 


39 l A 


5 


11 


124 


132 


I6 5 


206 


23-1 


a° i A 


6 




127 


136 


I70 


212 


238 


41 


6 


1 


131 


140 


175 


219 


.245 


41 K 


6 


2 


135 


144 


l8o 


225 


252 


42X 



Table Showing the Expectancy of Life for Each Year, 

from 15 to 85, According to the "Actuaries' 

Combined Experience." 





EXPECT' D 




EXPECT' D 




expect'd 




expect'd 


AGE. 


YEARS 


AGE. 


YEARS 


AGE. 


YEARS 


AGE. 


YEARS 




OF LIFE. 




OF LIFE. 




OF LIFE. 




OF LIFE. 


15 


44.96 


33 


3 2 -3° 


51 


I9.50 


69 


9.OO 


16 


44.27 


34 


31-58 


52 


18.82 


70 


8-54 


17 


43-58 


35 


30.87 


53 


I8.l6 


71 


8.IO 


18 


42.88 


36 


30-15 


54 


I7-50 


72 


7.67 


19 


42.19 


37 


29.44 


55 


16.86 


73 


7.26 


20 


41.49 


38 


28.72 


56 


16.22 


74 


6.86 


21 


40.79 


39 


28.00 


57 


15-59 


75 


6.48 


22 


40.09 


40 


27.28 


58 


14.97 


76 


6.11 


23 


39-39 


41 


26.56 


59 


14-37 


77 


5-76 


24 


38.68 


42 


25.84 


60 


13-77 


78 


5-42 


25 


37-98 


43 


25.12 


61 


13.18 


79 


5-09 


26 


37-27 


44 


24.40 


62 


12.61 


80 


4.78 


27 


36.56 


45 


23.69 


63 


12.05 


81 


4-48 


28 


35-8 6 


46 


22.97 


64 


11.51 


82 


4.18 


29 


35-15 


47 


22.27 


65 


10.97 


83 


3-9o 


30 


34-43 


48 


21.56 


66 


10.46 


84 


3-63 


■ 31 


33-72 


49 


20.87 


67 


9.96 


85 


3-36 


32 


33-oi 


5o 


20.18 


68 


9-47 







UNION MUTUAL LIFE INSURANCE COMPANY. Hj? 

give the date of birth correctly, and to make the age at nearest birthday coi 

respond therewith. Be particular, also, that answers relative to benefit Iarii 
plainly written, and non-conflicting one with another. Another important 
point, too frequently overlooked, is explicitness in stating the exact kind of 
business followed by the applicant; for instance, if "merchant" or "clerk," 
what kind of goods does he handle ? If "bookkeeper," what kind of business 
does his firm engage in ? etc. 

JS^** Finally, let it be some one's special work to take every application, 
when completed, and inspect the answer to each question, so that, if errors or 
omissions are found, they may be corrected before the application is sent in to 
the Home Office. Let this be an inflexible rule : it will save much time and 
vexation. 

INSTRUCTIONS TO OUR MEDICAL EXAMINERS. 

GENERAL RELATIONS TO COMPANY. 

Having signified your willingness to act as Medical Examiners for the 
"Union Mutual," you will naturally wish to know what is expected of you in 
that capacity, and also to be put in possession of any special views of the 
Company relative to the character of the risks which it seeks. 

Honesty, care, good judgment, and the general knowledge possessed by 
well-qualified practitioners of medicine are all necessary to make good Exami- 
ners for life insurance. We will therefore touch only on a few of the points 
about which it is well for the physicians of this Company to be advised, and 
in addition thereto, insert some practical hints concerning the examination of 
urine, for the sake of those who may not be altogether familiar with such 
simple and satisfactory tests. 

Those who have had experience as Examiners for Life Companies are 
already familiar with the usual forms and documents in use, and will have but 
little to learn concerning our own in particular. For those who are not so 
familiar, it will be well to procure from the Company's Agent one of the blank 
applications, and carefully peruse it, so as to get used to it ; for it is quite 
lengthy, and this will save time at examinations. 

Examiners for this Company are appointed only through the Medical 
Director at the Home Office. 

When one is appointed his name is regularly entered in the Company's reg- 
ister, and he is considered the sole Examiner in the town for which he is 
appointed, except where, in cities and large towns, it is found necessary to 
have more than one Examiner to meet the requirements of the Agency. It is 
always the wish and purpose of the Company to confine the business of exam- 
ining in any locality to as few hands as possible, believing this to be best for 
all concerned. 

BUSINESS RELATIONS WITH COMPANY. 

Agents are required to supply Examiners with the billheads issued by the 
Company, and medical gentlemen are particularly requested to use these 
instead of their own personal headings. 

All accounts for medical examinations should be sent direct to the Home 
Office, at the close of each month, no matter how small the bill, as the Com- 
pany desires to pay all such bills monthly. 



I98 HOW TO EXAMINE FOR LIFE INSURANCE. 

It will be a great accommodation to the cashier at the Home Office, if bills 
are receipted before forwarding. This request is made, because of the frequent 
delay, and often entire neglect, in returning receipted vouchers, after the Com- 
pany's checks have been sent out in liquidation of bills. (The above request 
is very generally complied with ; and it will not seem unreasonable, when it is 
remembered that the vouchers are very necessary for the Auditing Board of the 
Company, and that mistakes, or delays in accounts, are far less likely to occur 
in an institution where everything is reduced to system than among those 
fully occupied with professional duties, and who have little taste for clerical 
work.) 

The Company will pay for examinations, whether the parties examined are 
approved or rejected by the Examiner, the only exception to this being in the 
cases of those who present themselves for re-examination, the object being to 
restore a policy that has lapsed. In these cases, the party examined must pay 
the fee ; and the physician will notice that the form used for such examination 
(the party usually bringing it with him) has attached to it a receipt to be signed 
by the Examiner himself, in which it is acknowledged that the party examined 
has paid the fee. 

RELATIONS TO AGENTS. 

Medical Examiners, being appointed by the Home Office, are consequently 
independent of the Agent ; but it is for the interest of all concerned that har- 
mony and concert of action should exist between the Agent who solicits and 
the physician who examines the risks. The work of the solicitor is difficult, 
and often discouraging in itself, and it is of prime importance that applicants 
should be examined promptly when once they are in the mood for insurance, 
and we trust our Examiners will endeavor to accommodate Agents with prompt 
examinations. 

Examiners are sometimes charged with "throwing cold, water" on the 
Agent's work, by remarks or questions to the party under examination, having 
a tendency to impair his confidence in the wisdom of the step he is about taking. 
This is all wrong. A physician who is an unbeliever in Life Insurance should 
never act as the Exami?ier of a?iy Company ; or at any rate, while acting as the 
trusted adviser of a Company, he should never say or do anything to dissuade 
those who have decided to insure. A few words fro?n the Doctor may either 
destroy or co7ifirm the effect of 7nuch hard work on the part of a faithful Agent. 

The Company does not ask or expect its Examiners to put themselves out 
to introduce Agents in a community ; but, whenever physicians choose to do 
this voluntarily, their cooperation will be most welcome. The more good appli- 
cants for insurance, the better for both Cojnpany and Medical Exayniner ; and 
to this extent the Examiner, in helping the Agent, is helping himself and this 
is perfectly proper. 

Agents, knowing the value of a physician's influence, will sometimes 
endeavor to secure his assistance in their soliciting work, by offering him a part 
of their " commissions " on risks procured through his aid. This is not right, 
as it has a tendency to bias the opinion of the Examiner in favor of the appli- 
cant (or Agent, which is the same thing) instead of the Company: therefore, 
in no case must an Examiner have any pecuniary interest (other than his fees 
for examination) in the placing of risks in the Company. 



UNION MUTUAL LIFE INSURANCE COMPANY. 
THE APPLICANT AND Tin EXAMINATION. 

It is expected that subjects for medical examination will present th 
at the physician's office, but it will QC casionally happen that an individual either 
cannot or will not do this; and, in such exceptional cases, it is customary foi 
the Examiner to visit the individual, and make the examination at the usual 
fee. If, in any such case, however, the Doctor is called to conduct his examina- 
tion in a place decidedly unfitted for it, he will, of course, decline to do it. 
instance, a satisfactory examination cannot be made in a public store or office, 
or in a noisy machine-room ; while, on the other hand, a farmer might be 
examined in his field, or a mechanic in a quiet shop, or a merchant in his 
private office. 

Medical Examiners should insist upon being alone with the applicant when 
examination is made. 

In conducting the examination, the main points are : first, to ascertain if the 
applicant himself is, at the time of examination, in a condition of sound mental 
and physical health ; and, second, to get as positive and clear statements as 
possible relative to the personal and family history, with a view to discover any 
latent tendency to hereditary diseases which may exist, and to ascertain if any 
pernicious habits, either past or present, have impaired the chances for living 
out the " Expectation " with which the applicant, at his age, is credited in the 
table preceding; and every applicant for insurance should be subjected to a 
thorough personal examination, no matter how familiar the examining physi- 
cian may be with him or his family history. 

Physicians, in the ordinary examination of patients, have usually in view 
only the ascertaining of present conditions. Here, however, it is with the 
future as well as the preseiit that the Examiner has to interest himself; for it 
is not enough for his purpose that disease does not now exist, but he must seek 
also for reasonable assurances that it is not likely to develop in the future. 

If he cannot find such assurance, he must be careful how he recommends 
such a risk. 

Care should be taken to answer all questions correctly and fully, and any 
diseases from which the applicant has suffered in the past should be noted ; 
and, if serious, their date and duration given. 

Especially should this be done with reference to rheumatism. 

Habits, past and present, should be carefully inquired into, and clearly 
explained, so that there shall be no doubt as to what is meant. Such answers 
as "uses some," "takes a drink when he wants it," "quite temperate," or 
"fairly temperate," should not be used. " Temperate " is an entirely relative 
term, and may mean almost anything (according to the view of the party using 
it), from teetotal down to daily tippling. If alcoholics or beer are used, the 
Examiner should find out and state which, how frequently, and under what 
circumstances. If habits have been bad in the past, state full particulars. 
Reformed drinkers, as a rule, are not desirable risks. 

When considering the " family record," care should be taken to bring out 
all the points as distinctly as possible ; and, if the applicant answers that he 
"doesn't know " the disease from which his parents or brothers and sisters 
have died (or suffered), the Examiner should direct his questions so as to satisfy 
himself, as far as he can, what the probabilities are. This he can do by eliciting 



200 HOW TO EXAMINE FOR LIFE INSURANCE. 

some history of the symptoms attending- the sickness and death, the duration 
Of the disease, etc. ; and if, in his opinion, there is reason to suspect phthisis or 
other diseases of an hereditary nature, let him so state. Vague expressions, 
such as " general debility," " change of life," "run down," etc., should not be 
accepted as answers. Applicants, generally, are well aware how strongly it 
operates against them to state that members of their families have died of 
consumption, etc. ; and they will frequently endeavor to avoid the admission 
by saying they " don't know," hence it requires tact, many times, to get at the 
truth. If they really don't know, some good reason for their ignorance can 
usually be given. 

When answers are made that mother or sisters have died in childbed, the 
Examiner ought not to accept this answer as final until he has made inquiry 
as to the previous health, length of time sick, etc., to satisfy himself whether 
there was not some other cause operating back of the one alleged ; and, if it 
is found that the deceased was weakly or consumptive, such fact should be 
stated. 

In measuring the chest of the applicant, keep the tape line fairly tight, so 
as to get correct inspiration and expiration measure. Never measure outside 
the waistcoat, but apply the tape next the linen or under vest, crossing the 
lower borders of the scapulae, and just above the nipples. 

EXAMINATION OF URINE. 

It is frequently the case now that the Company requires an examination 
of the applicant's urine. In applications for $5000 and over, and where appli- 
cant is 45 years of age or over, this is invariably the rule. This examina- 
tion, to be of value, should be both chemical and microscopical, and carefully 
made. 

Doubtless most of our Examiners have settled methods of their own by 
which to conduct these examinations, and it is not our intention to prescribe 
any rules for the work ; but it may not be altogether superfluous to take a hasty 
glance at the subject, and to mention some easy and simple methods which 
are, at the same time, accurate and reliable. 

Healthy urine should be clear, of a straw or amber color, with an odor 
characteristic of itself, and the reaction slightly acid, though it may become 
neutral, or even slightly alkaline, during the period of digestion. If violet 
litmus paper be used, it will be turned red by acid urine, blue by alkaline, and 
remain unaffected by a neutral urine. 

The specific gravity should be somewhere between 1.015 and 1.028 or 30: 
the more concentrated and smaller in quantity, the greater will be the sp. gr., 
and vice versa. 

The two most important abnormal substances found in solution in urine are 
albumin and sugar. 

TESTS FOR ALBUMIN. 

Albuminous urine is generally of low sp. gr. 

In testing for albumin, first see that the test-tube is perfectly clear and 
bright; and, second, that the urine to be tested is clear. If it is opalescent or 
cloudy, it may be made clear by filtering through the ordinary filter paper, 
obtainable of any druggist. 



UNION MUTUAL LIFE [NSURANCE COMPANY, ! I] 

To Test by Beat.— Fill the tube about three-fourths lull of the clear urine, 
which, if not distinctly acid in its reaction, should be rendered so by adding 
to it a drop or two of acetic acid (U. S. Thar.), and then, holding the tul 
the lower end, boil the upper strata of the fluid over a spirit or other hoi flame 
(spirit is best, as it leaves the glass clear for observation). It should be allowed 
to boil for several seconds, and, if the least cloud or opacity appears in the 
urine, it is due to one of two things, cither albumin or earthy phosphates. 
If it be the latter, it will promptly disappear on the addition of a few drops of 
nitric acid ; if it be albumin, it will remain permanently. 

The quantity of albumin precipitated will, of course, depend on the quan- 
tity held in solution in the urine, and may range anywhere from a faint cloudi- 
ness to a dense abundant precipitate. If the albumin be in considerable 
quantity, it will be easily recognized ; but as it is very essential that the smallest 
presence of albumin should be detected, it will be necessary to inspect the tube 
closely ; and, in the way of a hint how to do this to best advantage, I cannot 
do better than quote the directions given by Dr. A. H. Buck, of New York. 
He says (after speaking of boiling) : " The tube should then be held at arm's 
length in front of, and near to, a dark background, over the top of which a 
light is allowed to enter the room through a comparatively small opening. By 
moving the tube slowly up and down from the dark region below into the light 
above, and the reverse, a position will be found in which the slightest cloudi- 
ness of the fluid can be detected." To do this " in the daytime, the room can 
be darkened sufficiently by lowering an opaque window-shade to within a few 
inches of the sill. A dark coat thrown over the back of a chair which stands 
immediately beneath the window, will furnish the desired dark background. 
At night, a shaded kerosene lamp, in front of which a dark-covered book is 
placed to serve as a background, and also to cut off some of the rays of light, 
will answer an equally good purpose." 

The test by nitric acid may be thus made : — 

Into a clean, small test-tube pour from half a drachm to a drachm of color- 
less nitric acid, and upon this allow a couple of drachms or so of the urine to 
gently trickle down from a pipette, the tube being held in an inclined position, 
so that the urine may flow gently along its lowest side. If albumin be present, 
a grayish white line, more or less dense, will form like a diaphragm, dividing 
the acid and the urine at the point where the latter rests upon the former. As 
this line, however, does not always form at the moment, it is better to set the 
tube aside, for a few minutes at least, and then observe it. 

Another way of reaching the same result is to put first a quantity of urine 
into the tube (a quarter to a third full), and then, holding the tube obliquely as 
before, allow the acid to trickle from the pipette along the side of the tube, so 
as to run under the urine (the acid being the heavier of the two liquids), and 
accumulate in the bottom of the glass. On allowing it to stand a few minutes, 
the albumin will appear in the white line or band, as before described, just at 
the junction of the two fluids. Some practice with the pipette is necessary to 
prevent the fluid it contains, be it acid or urine, from rushing too violently into 
the fluid in the tube, and thus mixing one with the other ; for the success of the 
trial depends on keeping them from mixing, and only allowing one to rest on 
the other. The best way to avoid this is to have the upper end of the pipette 



202 HOW TO EXAMINE FOR LIFE INSURANCE. 

roughened, and to rotate it between the thumb and middle finger, as directed 
by Tyson in his handbook. 

In searching for albumin, apply both the heat and nitric acid tests. 

SUGAR TEST. 

If sugar be present in the urine, we shall generally find a high sp. gr., but 
not invariably so. An easily prepared and yet reliable test for sugar is that 
recommended by Prof. Haines, of Chicago. It is made as follows : — 

Formula. 

Pure sulphate of copper thirty grains. 

Pure glycerine two fluid- drachms. 

Pure caustic potash, in stick one and a- half drachms. 

Pure water six fluid-ounces. 

Dissolve the sulphate of copper and glycerine in a portion of the water and 
the caustic potash in the remainder; mix the two solutions, when a perfectly 
clear, transparent, dark-blue liquid should result, which may be bottled and 
set aside for use. As usually made, it generally throws down a slight reddish 
deposit, upon standing a week or two. This, however, does not affect its value 
as a test. In using, simply decant the clear liquid from the sediment. 

In preparing the above solution, if pure caustic potash in sticks cannot be 
obtained, we may use instead 3% fl. ounces of the officinal liquor potassae, at 
the same time reducing the quantity of water used to 2)4. A- ounces, the other 
ingredients remaining as above. 

Directions for Use. — Take about one fl. drachm of the test solution, and 
gently boil it, when no change should take place ; now add eight or ten drops 
of the suspected urine, and again bring to a boil. If sugar be present, an 
abundant yellow or yellowish-red precipitate is thrown down ; if no such yellow 
or yellowish-red precipitate appears, no sugar is present. 

N. B. — A white flocculent deposit, often thrown down, consists of phosphates, 
and does not indicate sugar. 

The microscopic examination is for the purpose of determining whether the 
deposit contains casts of the uriniferous tubes, epithelium, crystalline matter, or 
such small quantities of pus or blood as would not be easily recognized by 
other tests. Every one who is familiar with medical microscopy understands 
how to make the search, and we would only suggest that specimens be taken 
from the top and middle of the " deposit cloud," as well as from the bottom. 

Finally, in every case where the Examiner has a doubt of the desirability of 
the risk, he must give the Company the benefit of the doubt. 

All physicians accepting the office of Medical Examiner are expected to 
answer letters from the " Home Office," free of charge, and promptly. 

SPECIAL INSTRUCTIONS. 

It appears that considerable unproductive work has been done by our Agents 
in times past, and much trouble and labor caused at the Home Office from 
a failure to clearly understand the rules and regulations of the Company. 

We send this circular out in hopes that it may be the means of diminishing 
this disagreeable and unnecessary labor. 



UNION MUTUAL LIFE INSURANCE COMPANY. 203 

The management at the Home Office fully appreciate the difficulties under 
which Agents labor, and are anxious to give them all the help possible. Hut it 
must be borne in mind by all that the safety and success of the Company 
largely depends upon the character of risks taken. 

Great care has been taken, at no little expense, to select a competent board 
of Medical Examiners, whose faithful and conscientious services are fully 
appreciated at the Home Office, and there recognized as of the first import- 
ance. 

Agents must not expect or attempt to select their Medical Examiners. 

Whenever an Agent determines to take applications in a place, his first 
business should be to learn who the Medical Examiner for that place is. If 
none is appointed, he should notify the Home Office of the fact in time, so that 
one can be ready for him when needed. It sometimes takes a week or two to 
arrange this matter. 

All applications received at the Home Office, where these rules are not com- 
plied with, will be held for explanation. 

It is not only discouraging to Agents, but also disagreeable to applicants and 
Medical Examiners, and expensive to the Company, to have applications re- 
jected. And we feel that with proper care and a thorough knowledge of the 
rules of the Company, very few rejections need be made. 

Agents should not take it for granted that a person is a safe risk, because he 
looks healthy and says he is well. His own and his family history, his habits 
and occupation, his relative height and weight, and various other things that 
have a bearing upon the character of the risk, should be taken into considera- 
tion by every Agent before an application is filled out. Honest and straight- 
forward work always pays the best in the end. Care and thought save many 
missteps. 

Our local Medical Examiners are or should be constantly on picket duty, 
and no Agent has a right to expect them not to notify the Company of approach- 
ing danger. Some of course recommend applicants on their personal examina- 
tions, that the Medical Director feels obliged to reject after considering all the 
bearings of the case. 

It is an easy matter for an Agent to get applications from persons who are 
not insurable. Such are always willing to try for insurance in any Company; 
but to write such up and get them examined is only time wasted by the Agent 
and expense to the Company for nothing. 

If every Agent will carefully avoid receiving applications from the following 
classes of persons, much less rejection will be necessary : — 

1 st. Persons prohibited by rules of the Company as shown by the "Agents' 
Manual." 

2d. Persons who have been rejected by any Insurance Company within 
two years. 

3d. Persons drawing pension on account of disease. 

4th. Persons who have coughed and spit blood. 

5th. Persons who have been troubled with palpitation of the heart, or have 
had gout. 

6th. Persons who have had rheumatic fever within a year, or several attacks 
within ten years. 



204 HOW TO EXAMINE FOR LIFE INSURANCE. 

• 

7th. Persons 1 5 per cent, under weight, who have lost relatives from con- 
sumption ; and all persons who are 25 per cent, under weight. 

8th. Persons under 40 years of age who have lost several near relatives, as 
both parents, or one parent and one or more brothers or sisters, or several 
brothers and sisters, from consumption. 

9th. Persons 25 per cent, over weight who have lost relatives from apoplexy 
or heart disease, and all persons who are 40 per cent, over weight. 

10th. Persons who have or have had any form of cancer or paralysis. 

nth. Persons who are deaf and dumb or blind. 

1 2th. Persons who have had hip disease or disease of spine or other well- 
formed mark of scrofula. 

13th. Persons who have had thigh amputated high up so as not to be able 
to wear an artificial limb easily. 

While these cases, as a rule, had better be left alone, now and then an excep- 
tional case may be favorably considered. If, therefore, an Agent meets with what 
he believes to be a worthy case among them, he should report it to the " Home 
Office," and await instructions before putting the Company to the expense of a 
medical examination. 

If all Agents will carefully follow out these suggestions, we shall not find, as 
we do at present, 20 or 25 per cent, more rejections from one Agency than from 
another. 



WASHINGTON LIFE INSURANCE COMPANY. 

INSTRUCTIONS TO THE MEDICAL EXAMINERS. 

Life Insurance on the mutual plan is a business carried on for the mutual benefit 
of those insured ; to make the business successful, or even safe, at the premiums 
charged, the risks must he selected ones. Many persons awake to the importance 
of Life Insurance only when they begin to suspect that their health is failing; 
a few deliberately attempt to swindle Companies by obtaining insurance on 
unsound lives, in which they have an interest ; others apply in full confidence 
of their own soundness who are already laboring under disease or tendency to 
disease likely to result in premature death. The Examining Physician stands 
between such parties and the Company ; to insure the success of the latter, he 
must be competent, and must do his duty carefully and thoroughly. His 
interests are identical with those of the Company. Careful Examiners are 
soon known and valued ; the knowledge of their ability, care and integrity 
extends from one office to another, and cases otherwise in doubt may occasion- 
ally be accepted from confidence in their judgment. 

As a further safeguard, the applications are all submitted to the physician at 
the Home Office. To enable him to form an opinion of the case, every fact 
which influences the judgment of the examining physician should be stated in 
the application. 

The examinations should always be made in private; no one to be present 
but the Examiner and the applicant. 

The medical Examiner is required to read over carefully the applications of 
those desiring insurance and see that all the questions are fully and explicitly 
answered. If any of the answers require explanation, the applicant should be 
further questioned by the physician, and the facts elicited bearing on the case 
noted in the application itself. 

The question regarding the occupation of the applicant is often answered in 
too general a manner. The applicant is a mechanic, merchant, etc. Some of 
the mechanical occupations, e.g. those of the tailor, the shoemaker, the printer, 
carried on often in confined rooms and in cramped positions of the body, arc 
unfavorable to longevity, and in doubtful cases may incline the Company to 
grant only a limited payment policy, or to decline the application altogether ; 
on the other hand, the objection would not apply, if the applicant were engaged 
only in supervising the manufacture or in the sale of the articles produced. A 
bookkeeper is a less desirable risk, other things being equal, than one whose 
occupation compels him to a more active life. 

Those whose occupations expose them to the inhalation of dust — stone- 
cutters, miners, millers, etc. — are more liable to pulmonary complaints, other 
things being equal, than those who are not specially subject to such causes of 
irritation. 

The general experience of Life Insurance Companies has proved that those 
engaged in the sale of intoxicating liquors are exceptionably bad risks. Dr. 

205 



206 HOW TO EXAMINE FOR LIFE INSURANCE. 

John Dickenson, of London, states : the average duration of life of liquor 
dealers is shortened by three and a half years. 

If the applicant has had rheumatism, the character of the attack, whether 
acute or chronic, the date of its occurrence, and whether there has been one or 
more attacks, should be carefully noted. It is estimated that in acute rheu- 
matism the heart is affected in as large a proportion as one-third of all the 
cases. The younger the applicant at the time the attack occurs, the greater 
the liability to heart disease, and when it has occurred in infancy or early 
childhood, this alone is a valid ground for rejecting the risk. Rheumatism, too, 
is often an hereditary disease, and if the applicant has had an attack, the family 
history in this respect should be noted. 

If the applicant has had gout, the age at which the attack first occurred, its 
character, severity and the number of attacks, should be given. As in the case 
of rheumatism, here also the family record should be searched for evidence of 
hereditary taint. 

When the applicant has been subject to attacks of asthma, the nature of the 
attacks and the frequency of their occurrence should be inquired into. Some- 
times it is only the rose-cold or hay-asthma, as it is termed ; sometimes there 
may be emphysema or heart disease. In all suspicious cases the chest should 
be exposed, carefully examined, and the results, favorable or unfavorable, given. 

If the applicant states he has had disease of the urinary organs, its nature 
and duration should be given ; sometimes it turns out to be a simple lumbago, 
or attack of muscular rheumatism. If gravel is mentioned, it should be stated 
whether it was a simple deposit of urates, or whether a small calculus had been 
passed ; if the latter, it should be ascertained whether more than one stone has 
passed, and if so at what intervals of time, and the date of the occurrences 
should be noted as nearly as possible in the application. 

In the examination of the urine, after ascertaining the amount in twenty- 
four hours, the specific gravity and the reaction, it should be tested for albumin 
and sugar. The simplest and most trustworthy tests for albumin are the 
nitric acid test and the heat test. The nitric acid test is made as follows : 
Fill a test-tube about one-third full of urine, then, inclining the tube, pour 
in strong nitric acid in such a manner that it may trickle down along the 
side of the tube to the bottom and form a stratum a quarter of an inch thick 
below the urine ; or better still, the nitric acid may be introduced below the 
urine by means of a pipette. If albumin be present, an opalescent zone will 
be observed at the point of contact of the urine and the nitric acid. If there 
be only a trace of albumin present, some twenty or thirty minutes may elapse 
before the zone becomes visible. Should a cloudiness be observed, due to 
amorphous urates, the application of heat will cause it to disappear, whereas 
the turbidity from albumin is not affected by heat. The urine of patients who 
are taking cubebs and copaiba is usually somewhat opalescent, and nitric acid, 
in the cold, sometimes increases the opalescence. The sense of smell will 
direct attention to the presence of these drugs, and heat diminishes the opales- 
cence and prevents any turbidity with nitric acid. 

The best manner of applying the heat test is to fill a test-tube two-thirds 
full of urine, add one or two drops of acetic acid and then boil the upper por- 
tion of the column of urine. If albumin be present, the upper boiled portion 



WASHINGTON LIFE INSURANCE COMPANV. 2C>7 

of the urine will show opalescence, in contrast to the lower half, which remains 
unchanged. The points of importance in this test are : (<i) not to add too mu< h 
nor too little acid, and (b) to boil only the upper pardon of the urine. In all 
tests for albumin the tube should be held in a strong light against a dark back- 
ground. Of the various tests for sugar, that of Fehling's is preferred, per- 
formed as follows : Fill a test-tube to the depth of one inch with Fehling's 
solution ; heat until it begins to boil, and then add a drop or two of the sus- 
pected urine. If it be ordinary diabetic urine, the mixture, after an interval of 
a few seconds, will turn suddenly to an intense opaque-yellow color, and in a 
short time an abundant yellow or red sediment falls to the bottom. If, how- 
ever, the quantity of sugar present be small, the suspected urine is added more 
freely, but not beyo?id a volume equal to that of the test e7nployed. In this latter 
case the mixture should be raised once more to the boiling point. It is then 
allowed to cool slowly. If no suboxide has been thrown down when it has 
become cold, then the urine may with certainty be pronounced sugar-free. The 
precautions to be observed in this proceeding are : (1) to boil the test first and 
not the urine, and (2) to use an excess of the test. 

If the applicant has had syphilis, the date of the i?iitial lesion should be 
given, as well as the subsequent history of the case (secondary or tertiary symp- 
toms, nature and duration of treatment, etc.). The interval which has elapsed 
since last appearance of symptoms of the disease should be ascertained and 
stated. 

If the applicant has had stricture, full particulars should be given, includ- 
ing cause (gonorrhceal or traumatic), treatment, date of cure and present state 
of urethra. 

Rupture, if it exists, should always be stated. When easily reducible and 
retained by a well-fitting truss, it forms no necessary bar to insurance, but the 
existence of an irreducible hernia renders the subject uninsurable. 

The disease from which Life Insurance Companies suffer most is consump- 
tion, and all questions bearing upon this subject should be carefully scrutinized. 
If the patient has suffered from haemoptysis, its extent, duration, and period of 
occurrence should be given. Often applicants do not know the disease of which 
members of their immediate family have died, or return it as general debility, 
change of life, dropsy, bronchitis, pneumonia, exposure, rupture of blood vessel, 
effects of accident, old age, etc., and in such cases inquiry should be made, and 
if it proves that death has occurred after a lingering, wasting disease, attended 
with cough, the probability is that it occurred from phthisis. Mothers or sisters 
are often reported as dying of childbirth, while inquiry will elicit the fact that 
they have died many weeks after childbirth, of wasting disease, which was 
attributed to that cause. The results of inquiry in all these cases should be 
carefully and fully noted in the application. This will avoid much delay and 
unnecessary correspondence with the Home Office. In all cases where a tendency 
to consumption is suspected, the present health of the surviving members of the 
family s"hould be scrutinized with particular care. Where any doubt may exist, 
the longevity, etc., of the uncles and aunts should be inquired into. Where 
father and mother have died at an early age from acute disease, or accident, 
the history of the members of their immediate family, the uncles and aunts of 
the applicant, should be inquired into and stated. 



2o8 HOW TO EXAMINE FOR LIFE INSURANCE. 

The age of both paternal and maternal grandparents should be given ; if 
any of them have died prematurely, the disease, if possible, should be ascer- 
tained and stated ; when the applicant is ignorant of the age at death, the fact 
should be stated. 

The report of the Medical Examiner should invariably be written and signed 
by himself. He should weigh and measure the applicant when possible, but if 
not, he should estimate the weight and height as accurately as he is able ; 
ascertain, by feeling, the fullness and firmness of the muscles, and state 
whether the figure is erect or bowed, slender or robust, and whether the com- 
plexion is pallid, healthy, or too high colored. 

He should learn and state if the applicant has notably lost or gained flesh 
within the last five years. When there is any hereditary predisposition to con- 
sumption, or where the habit of body is particularly slender, the chest should 
be exposed, and great care taken to ascertain if the expansion of the chest be 
free and equable, if there be any want of symmetry in the two sides, if there be 
any sinking in under the clavicles, and if auscultation and percussion give 
normal results. 

If the applicant has had rheumatism, or complains of palpitation, the 
region of the heart should be exposed, the point of the apex beat (normally in 
the fifth intercostal space, and about one inch within the left nipple) should be 
noted, and any abnormal murmur attentively listened for. The pulse should 
always be felt prior to the examination of the chest, which is apt to quicken and 
excite it. 

Next to consumption, if not equal to it, the abuse of alcoholic liquors, 
fermented as well as distilled, causes in our experience the greatest loss to Life 
Insurance Companies. Where there is the slightest doubt of the applicant's 
habits, the question should be distinctly put, and the amount of daily consump- 
tion, and the facts as to occasional excess should, so far as possible, be ascer- 
tained and entered on the application. An observing physician will often learn 
much from the applicant's complexion and general appearance. 

Occasionally some particulars in regard to the history or health of the appli- 
cant may be suspected or discovered which the Examiner may not desire to 
enter upon the application : in such cases a private letter may be written to' the 
Medical Examiner at the Home Office. 



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